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Full text of "Report to Congress : monitoring the impact of Medicare physician payment reform on utilization and access"

HEALTH CARE FINANCING ADMINISTRATION 




0^1 



Report to Congress 

Monitoring the Impact of Medicare 

Physician Payment Reform 

on Utilization and Access 



HCFA Pub. No. 03358 
September 1994 



For sale by ihe U.S. Government Printing Office 
Superintendent of Documents, Mail Stop: SSOP, Washington. DC 20402-9328 
ISBN 0-16-045304-6 



Table of Contents 

Executive Summary E-1 

Glossary of Terms G-1 

INTRODUCTION 1 

PART 1. BACKGROUND 1 

Information about OBRA 1989 1 

Payment reform is part of a continuum 2 

Defining and measuring access 2 

Basic approach 4 

Major issues addressed 5 

Data sets 5 

Studies conducted for this report 6 

PART 2. MAJOR FINDINGS 7 

A. Did the MFS invoke the kinds of payment changes 

anticipated? 7 

B. Has the MFS presented new barriers to access for 

vulnerable populations 11 

Access measure 1: Use of ambulatory visits 11 

Access measure 2: Percent with a health problem and 

not receiving care 16 

Access measure 3: Use of preventive services 16 

Access measure 4: Hospitalizations for ambulatory care 

sensitive conditions 19 

Access measure 5: Referral sensitive procedure rates 21 

C. What have been the impacts of the MFS on physicians' practices? 23 

PART 3. DISCUSSIONS AND CONCLUSONS 25 

Conclusions 26 

Summary 27 

ACKNOWLEDGMENTS 28 

BIBLIOGRAPm^ 29 



T-1 



FIGURES: 


Figure 1 
Figure 2 


Figure 3 


Figure 4 


Figure 5 


Figure 6 


Figure 7 


Figure 8 


Figure 9 


Figure 10 


Figure 11 


Figure 12 


Figure 13 


TABLES: 

Table 1. 



Table 2. 



Table 3. 



Table 4. 



Total Allowed Charges by Specialty: 1991 and 1992 8 

Allowed Charges - MFS Physician Services 1990 to 1993, 

by Quarter, All Medicare Beneficiaries 9 

Ambulatory Physician Visits per 1,000 Persons 

1990 to 1993, by Quarter, by Age, Medicare 

Beneficiaries Age 65 and over 13 

Ambulatory Physician Visits per 1,000 Persons 

1990 to 1993, by Quarter, by Race, Medicare 

Beneficiaries Age 65 and over 13 

Ambulatory Phsycian Visits per 1,000 Persons by 

Population Density, by Quarter 14 

Ambulatory Phsycian Visits per 1,000 Persons by 

Ex Ante Impact Area, by Quarter 14 

Ambulatory Physician Visits per 1,000 Persons by 

County, by Quarter 14 

Physician Visits per Person per Year by Insurance 

Coverage: 1984 to 1990 15 

Percent of Persons Reporting a Health Problem and Not 

Receiving Care in Previous Year 17 

Mammography Use for Vulnerable Population Groups: 1991 

Rate for 1,000 Persons 18 

Ambulatory Care Sensitive Admission Rates for Vulnerable 

Population Groups: 1991, Rate per 1,000 Persons 20 

Heart and Vascular Procedures, Rate per 1,000 

Beneficiaries, by Race 22 

Mean Allowed Charges per Physician by Specialty: 

1991 and 1992 24 

Medicare Part B fee-for-service claims: Allowed charges 

by type of service, 1991 and 1992 31 

Medicare Part B fee-for-service claims: Allowed charges 
by type of service and physician/supplier specialty 
category, 1991 and 1992 32 

Medicare Part B fee-for-service claims: Allowed charges 
by physician specialty category: 1991, 1992, and 
preliminary 1993 33 

Medicare Part B fee-for-service claims: Allowed charges 
for physician services by place of service: 1991, 1992, 
and preliminary 1993 34 



T-2 



Table 5. Medicare Part B fee-for-service claims: Allowed charges 

for physician sen^ices covered by the Medicare fee schedule 

for procedures: 1990-93 35 

Table 6. Visits and consultations for vulnerable population groups: 1991 37 

Table 7. Percent of persons with a physician visit and mean number of 

visits per person by health insurance status: 

selected years, 1984-1990 38 

Table 8. Utilization, access, and satisfaction indicators, by age: 

1991-1992 39 

Table 9. Influenza immunizations per 100 persons for aged and disabled 

Medicare beneficiaries, by gender and race: 1993 40 

Table 10. Covered preventive service use for vulnerable population groups, 1991 . 41 
Table 11. Ambulatory care sensitive (ACS) admission rates for vulnerable 

population groups, 1991 42 

Table 12. Comparison of age-adjusted rates of selected procedures in 

elderly black and white Medicare beneficiaries, and 

30-day post-admission death rates, 1990 and 1992 43 

Table 13. Mean caseload per physician, by specialty group: 1991-1992 45 

Table 14. Mean allowed charges per physician, by specialty group: 1991-1992 ... 46 
Table 15. Primary care and medical specialties per 100,000 Medicare 

beneficiaries, by region, U.S. 1984-1992 47 

Appendix I Impacts of the Medicare Fee Schedule on Physicians/Suppliers 

and Procedures I-l 

Appendix II Beneficiary Access and Utilization II- 1 

Appendix III Monitoring Part A III-l 

Appendix IV Impact of the Medicare Fee Schedule on Access to Physician 

Services IV-1 

Appendix V Changes in Utilization, Access, and Satisfaction With Care 

Among Noninstitutionalized Medicare Beneficiaries V-1 

Appendix VI A Baseline Analysis of Utilization and Access From The 

National Health Interview Survey, 1984-1991 VI-1 

Appendix VII Trends in Physician Supply VII-1 

Appendix VIII Access to Care Before and After Fee Schedule 

Implementation: A Physician-Based Analysis VIII-1 

Appendix IX Other Relevant Activities and Future Work IX- 1 



T-3 



EXECUTIVE SUMMARY 

Purpose 

This report responds to the Omnibus Budget Reconciliation Act (OBRA) of 1989 
(Public Law 101-239) which amended the Social Security Act by adding Section 1848, 
"Payments for Physicians' Services." Section 1848 specified three major components of a 
new Medicare payment system for physicians' services: the development of a fee 
schedule; the establishment of limits on physicians' charges exceeding the fee schedule 
amount; and the establishment of processes to set target growth rates for expenditures 
for physicians' services. 

The major intent of this legislation was to provide more rational and equitable payment. 
The Medicare fee schedule led to a shift of Medicare payments from procedural services 
to evaluation and management services and from urban areas to rural areas. 

Section 1848(g)(7) requires the Secretary of the Department of Health and Human 
Services to monitor and report annually to Congress on changes in utilization and access, 
by population groups, geographic areas, types of services, and on possible sources of 
inappropriate utilization. 

Approaches 

Eight separate studies, with varied data sources and timeframes, were conducted to 
develop information about access to care in the period before and after the introduction 
of the Medicare fee schedule. The Health Care Financing Administration (HCFA) 
adopted a multi-dimensional framework for monitoring changes in access to care. First, 
HCFA selected several measures to serve as indicators of access to physicians' care. 
These access measures include: 

• Use of ambulatory visits; 

• Percent of persons reporting a health condition and not receiving any care 
in the previous year; 

• Use of preventive services; 

• Hospitalization rates for conditions that medical experts consider sensitive 
to appropriate and continuing ambulatory care; and 

• Use of referral sensitive procedures. 

Taken together, these measures provide a broad and significant set of indicators for 
monitoring access to physicians' care. 

E-1 



Second, several vulnerable population groups that are identifiable in HCFA's data 
sources are being monitored in order to determine if the new payment methods 
increased barriers that already may have existed or if they presented new barriers to 
care. These include beneficiaries who are: living under the poverty level; dually eligible 
for Medicare and Medicaid; black; disabled and under age 65; the very old (i.e., age 85 
and over); without supplemental health insurance; residing in rural areas; residing in 
areas designated as health professional shortage areas; and residing in areas expected to 
experience the greatest decreases in average Medicare fees. 

Third, three major policy issues were identified for study: 

1. Did the Medicare fee schedule invoke the kinds of changes anticipated 
with regard to shifts of Medicare payments from procedural services 
toward evaluation and management services? 

2. Did payment reform present new barriers to vulnerable populations? 

3. What have been the impacts on physicians' practices? 

Major Conclusions 

From the broad perspective taken for monitoring utilization and access to care for this 
report, as well as our knowledge of the Medicare program and other survey data, there 
are five principal conclusions that can be drawn: 

1. The Medicare fee schedule has produced the kinds of shifts in payments 
that were anticipated, by type of service, physicians' specialty, and 
geographic area. In particular, the introduction of the fee schedule was 
accompanied by a relative increase in allowed charges for visits and 
consultations and a relative decrease in allowed charges for procedure- 
based services. 

2. For vulnerable populations studied, no new barriers to care were found 
although there are clear indications that many population groups continue 
to face barriers to care. 

3. Improved health insurance coverage is an important factor in increasing 
access to care. 

4. Additional understanding is needed of barriers to care for vulnerable 
populations in order to further improve their access to care. 

5. Effective monitoring of access to care requires the development of more 
sensitive measures of access as well as better data sets and linkages to 
other information. 



ES-2 



Glossary 

AHCPR Agency for Health Care Policy and Research 

ACS Ambulatory Care Sensitive 

BETOS Berenson-Eggers Type of Service 

CABG Coronary artery bypass graft 

CHER Center for Health Economics Research 

CPT Current procedural terminology 

HCFA Health Care Financing Administration 

HCPCS HCFA Common Procedure Coding System 

HCQIP Health Care Quality Improvement Program 

HMO Health maintenance organization 

HPSA Health Professional Shortage Areas 

MAAC Maximum Allowable Actual Charge 

MCBS Medicare Current Beneficiary Survey 

MEDTEP Medical Treatment and Effectiveness Program 

MFS Medicare Fee Schedule 

MPIES Medicare Physician Identification and Eligibility System 

MVPS Medicare Volume Performance Standards 

NCH National Claims History 

NHIS National Health Interview Survey 

OBRA Omnibus Budget Reconciliation Act 

PORT Patient Outcomes Research Teams 

PRO Peer Review Organization 



G-1 



PTCA Percutaneous transluminal coronary angioplasty 

UCDSS Uniform Clinical Data Set System 

UPIN Unique Physician Identifier Number 



G-2 



INTRODUCTION 

This report is the Secretary's fourth annual report to Congress on monitoring access to 
care for Medicare beneficiaries. It responds to the requirements of the Omnibus Budget 
Reconciliation Act of 1989 to monitor the impact of Medicare physician payment 
changes on access to care. The report has three parts. Part 1 provides background 
information about the payment changes, identifies three major policy issues raised by the 
implementation of the payment changes, and discusses the approaches taken to analyze 
these issues. Part 2 summarizes important findings. Part 3 contains a discussion and 
conclusions. Eight separate studies were conducted for this report. They are included 
as appendices to the report. 

The Secretary's report to Congress in 1993 was based on preliminary data for 1992. 
Early data indicated that the new payment policies invoked the kind of changes intended 
by the legislation, and that the changes did not appear to have adversely affected access 
to care. This report, based on additional data, confirms those preliminary findings. 
Although there is no evidence to associate Medicare payment changes with increased 
barriers to care, this report shows persistent differences across population subgroups in 
most measures analysts use to monitor equity in access to care. 

PART 1. BACKGROUND 

Information about OBRA 1989. The enactment of the Omnibus Budget 
Reconciliation Act (OBRA) of 1989 (Public Law 101-239) brought about the most 
significant changes in Medicare physician payment policy since the program began in 
1966. These changes have three major components: 

• The introduction of a Medicare fee schedule (MPS) which was 
implemented beginning January 1, 1992 under a transition period ending in 
1996; 

• The establishment of limits on physicians' charges exceeding the fee 
schedule amount; and 

• The institution of target rates of growth in expenditures for physicians' 
services. 

The MPS was designed to bring about greater equity in physicians' payments between 
procedure-based services and primary care services, and greater equity across geographic 
areas because fees will vary only to reflect differences in practice costs. 

The new payment policies have potentially different impacts on the availability of 
physicians' services according to specialty and location. The MPS led to lower fees for 
physicians in surgical specialties and in urban areas relative to physicians in primary care 
and medical specialties and in rural areas. Physicians' services furnished in health 



professional shortage areas receive a 10 percent bonus. On unassigned claims, enrollees' 
liability can be no higher than 15 percent of the nonparticipating physician fee schedule 
amounts in 1993 and thereafter. 

At the same time, the changes in Medicare payment policies have potentially different 
impacts on the demand for services. Beneficiary liability for the coinsurance amount 
would be expected to increase for visits and consultations because the 20 percent will be 
based on higher amounts (although higher coinsurance may be offset by restrictions on 
extra-billings). The coinsurance amount would be expected to decrease for procedure- 
based services.^ 

Section 1848(g)(7) of Social Security Act requires the Secretary of the Department of 
Health and Human Services to monitor and report annually to Congress on changes in 
utilization and access, by population groups, geographic areas, types of service, and on 
possible sources of inappropriate utilization. 

Payment reform is part of a continuum. Before the OBRA 1989 reforms were 
instituted, a number of significant changes were initiated in physician payment policy 
that affected, and will continue to affect, utilization and access.^ Many other forces are 
also likely to continue to influence the demand for and supply of physicians' services 
received by Medicare beneficiaries, including the diffusion of new technology into the 
health delivery system. It is important, therefore, to view any changes found in access, 
utilization, and appropriateness in light of the many factors that may influence the health 
care system in general and Medicare in particular. 

Defining and measuring access. Access is viewed primarily as "...those dimensions 
which describe the potential and actual entry of a given population group to the health 
care delivery system" (Aday, 1984). In essence, measures of access are intended to 
reflect whether individuals are able to obtain appropriate care when needed. 

Measures of access can be grouped into two categories: potential access and realized 
access. Potential access refers to health care system characteristics (such as the supply 
of physicians and assignment rates) and individual characteristics (such as insurance 
coverage or having a regular source of care) that influence whether the individual 
obtains care. 



' Beneficiaries with supplemental health insurance policies generally are covered for the Part B 
coinsurance amounts and may not experience directly these changes as out-of-pocket liabilities. 

^ These include the implementation in 1975 of the Medicare Economic Index as a limit on increases in 
prevailing charges; the initiation in 1984 of the participating physician program to provide incentives for 
physicians to accept assignment; the introduction in 1987 of the Maximum Allowable Actual Charge 
(MAAC) limits which restricted the amount non-participating physicians could charge; the reductions in 
prevailing charges for overpriced procedures instituted for one group of procedures in 1988 and for 
another in 1990; and the institution of fee schedules for radiology in 1989 and anesthesiology in 1990. 



Realized access refers to the actual use of services and is generally measured in terms of 
utilization rates, often by specialty and type of service. Commonly used measures are 
the proportion of the population with at least one office visit and the hospital discharge 
rate. Realized access is a critical dimension, because it reflects whether individuals and 
population groups actually obtained services. 

We have learned that there are many facets of access to care. For example, Medicare 
data show that total physician visit rates and hospital discharge rates are similar for 
black beneficiaries compared to white beneficiaries. At the same time, there are striking 
differences between black and white beneficiaries in the rates of some procedures 
performed in the hospital, such as hip replacement and coronary artery revascularization. 
In discussing the variations in certain procedure rates across population subgroups, the 
Institute of Medicine's report, "Access to Health Care in America," (lOM, 1993) 
describes these procedures as "referral sensitive surgeries" because access to these 
procedures depends on the judgement of the physician who sees the patient first and 
decides whether to refer the patient for specialty care. 

Differences in utilization rates of various procedures are difficult to analyze, however, 
\yith most generally available data sets. A number of factors other than barriers to care 
can influence the use of these procedures, including differences in levels of severity of 
disease across population subgroups, differences in patient preferences, and the 
discretionary nature of many procedures. Nonetheless, substantial differences in 
utilization rates of referral sensitive procedures raise questions about barriers to care 
and point to the need to monitor these rates. 

From another perspective, analysts have suggested monitoring the hospitalization rate for 
such medical conditions as asthma or diabetes, which are sensitive to good ambulatory 
care, because high rates may be an indicator of barriers to appropriate and continuing 
ambulatory care. 

Accordingly, to gain a broad perspective, the following measures are being monitored for 
the Medicare population: 

Ambulatory visit rates. 

Percent of persons reporting a health condition and not receiving any care 
in the previous year. 

Use of preventive services. 

Hospitalization rates for conditions that are considered sensitive to 
appropriate and continuing ambulatory care. 

Use of referral sensitive procedures. 



The next sections provide an overview of the basic approaches used for monitoring 
access to care; the three major issues raised by the changes made in Medicare payment 
policies; and the data sets and studies performed to analyze these issues. 

Basic approach. The basic approach taken is to track these measures of access 
for the total Medicare population and for those vulnerable subgroups that are 
identifiable in the data sources used for this report. By vulnerable subgroups we mean, 
first, those population groups with characteristics that suggest they may have already 
been at-risk of not receiving needed care and may face additional risks because of the 
changes in payment policies. And, second, our definition also includes population 
groups who may be newly vulnerable because of the payment changes. The vulnerable 
population subgroups included in HCFA's monitoring are: 

• Beneficiaries who are living under the poverty level, who may face barriers 
to care because of income. 

• Beneficiaries dually eligible for Medicare and Medicaid, who may face 
barriers to care because of income and health status. 

• Black beneficiaries, who may face racial or socioeconomic barriers. 

• Disabled beneflciaries under age 65 and very old beneficiaries, who may 
face barriers because they have greater levels of chronic illnesses and 
continuing care needs, or because of their frailty. 

• Beneficiaries without supplemental health insurance, who may face 
barriers from out-of-pocket costs. (Increases in physicians' fees for visits 
automatically increase beneficiary coinsurance.) 

• Beneficiaries residing in rural areas, because the supply of physicians in 
rural areas is lower than average. 

• Beneficiaries residing in areas designated as health professional shortage 
areas (HPSAs). 

• Beneficiaries residing in areas expected to experience the greatest 
decreases in average Medicare fees, because the supply of services might 
be curtailed. 



In monitoring access for these vulnerable groups it is important to establish patterns of 
utilization and access in the period before the MFS went into effect.^ If these patterns 
are not understood, the effects of the MFS on access to care can not be discerned. 

Major issues addressed: The studies conducted for this report are directed at three 
major policy themes: 

A. Did the MFS invoke the kinds of payment changes anticipated: 

• With regard to the specialty of physicians serving Medicare 
patients? 

• With regard to the distribution of payments toward management 
and evaluation services (visits) and away from procedures? 

B. Has the MFS presented new barriers to access for vulnerable populations? 
This is the central question addressed in this report. 

C. What have been the impacts of the MFS on physicians' practices? 

Data Sets. To address these issues, HCFA is using both administrative and survey 
data. Medicare's administrative data are particularly valuable because they cover the 
entire Nation, and contain information for all beneficiaries, providers, and services 
rendered. 

To discern changes in patterns and trends on a timely basis, HCFA developed a 
monitoring system that produces quarterly data from the administrative data sets. The 
monitoring system contains three analytical files: (1) a beneficiary-based file to monitor 
rates of use of physicians' services for the total population, for demographic subgroups, 
and for geographic areas*; (2) a physician/supplier procedure summary file, to monitor 
aggregate changes in services and Medicare payments, within various physician specialty 



' The importance of understanding baseline trends for population subgroups is illustrated by the fact 
that studies of in-hospital procedures have found differences by race before the MFS went into effect 
(HCFA, 1990a; HCFA, 1990b; JAMA, 1990). Studies of revascularization procedures have also shown 
differences by gender before the MFS went into effect (HCFA 1990a; HCFA, 1990b; Ayanian and 
Epstein, 1991). Similarly, geographic differences have been observed in the supply of physicians and other 
providers of care for residents of rural areas compared to urban residents in the period preceding the 
MFS (Office of Technology Assessment, 1990; Hewitt, 1989). Thus, understanding the effects of the MFS 
on access to care for vulnerable subgroups of the Medicare population requires an understanding of 
patterns and trends in the period before the OBRA 1989 physician payment changes were made. 

'* The monitoring system uses a 105 procedure/service classification grouping system based on the 
HCFA Common Procedure Coding System (HCPCS). The HCPCS codes were grouped by the Urban 
Institute and HCFA into an analytical classification system, known as BETOS (Berenson-Eggers Type of 
Service). The BETOS is updated annually to incorporate the annual revisions and expansion of HCPCS. 



or supplier designations, across geographic areas, and by place of service; and (3) a 
physician file for a sample^ of physicians, to monitor trends in physicians' practices. 
This file links all Medicare carrier provider numbers with a unique physician 
identification number (UPIN) to analyze the services rendered by each physician in the 
sample.^ 

Although Medicare's administrative data sets are broad in scope, they are limited in the 
amount of information that is available to identify certain vulnerable groups. For 
example, beneficiaries without supplemental health insurance, or in poor health cannot 
readily be identified in the ongoing administrative data system. 

To remedy these problems, two national surveys are used because they gather more in- 
depth information about the characteristics of the population. Their major limitations 
lie in their sample size and in their frequency of collecting data, which restricts the types 
of analyses and monitoring that can be performed. 

The first survey used is the Medicare Current Beneficiary Survey (MCBS), which is 
sponsored by HCFA and implemented in 1991. The MCBS is especially valuable 
because it has a supplement each Fall that contains questions that are key to 
understanding-access, such as beneficiaries' health, insurance status, and barriers they 
may have experienced when care was needed. 

The second survey is the National Health Interview Survey (NHIS), sponsored by the 
National Center for Health Statistics. The NHIS adds to the knowledge available from 
the MCBS because it contains information about the U.S. population 18-64 years of age 
not on Medicare. The NHIS has special value because trends for both Medicare and 
non-Medicare populations can be followed from 1984. 

Studies conducted for this report. Eight separate studies were performed. Six of the 
studies were prepared by HCFA staff researchers, while the remaining two were 
conducted under a cooperative agreement with the Center for Health Economics 
Research (CHER). Because each of the studies was designed independently there are 
some differences across the eight studies in the way the subsets of the Medicare 



' The sampling rates vary inversely with the number of Hcensed physicians in a State, and range 
upward from 2 percent. The national sample equals over 5 percent of all U.S. physicians. 

* In 1989, HCFA implemented a national Medicare Physician Identification and Eligibility System 
(MPIES) registry that uniquely identifies physicians serving Medicare beneficiaries. In the past, it has not 
been possible to reliably assemble claims of individual physicians because of carrier-specific differences in 
assigning provider practice identification numbers. Physicians might be assigned more than one designated 
provider number if they practiced in different settings or if they had more than one designated specialty. 
Several physicians might have been assigned the same provider number if they practiced in a single- 
specialty group or clinic. Therefore, the UPIN system, when fully operational, offers the opportunity for 
monitoring physicians' responses to Medicare's physician payment reform. 



population were grouped. The major findings of all of these studies are summarized 
next 

PART 2. MAJOR FINDINGS 

The major findings are summarized according to the three issues that are addressed. 
A. Did the MFS invoke the kinds of payment changes anticipated: 

• With regard to the specialty of physicians serving Medicare patients? 

• With regard to the distribution of payments toward management and 
evaluation services (visits) and away from procedures? 



Figure 1 illustrates the shift in total Medicare allowed charges between 1991 and 1992, 
by specialty of the physician.^ Medicare allowed charges for physicians in primary care 
rose 13 percent, from $2,976 billion in 1991 to $3,376 billion in 1992. Similarly, allowed 
charges for physicians in medical specialties rose 3 percent, from $12,204 billion in 1991 
to $12.6Ll6-billion in 1992. In contrast, allowed charges for physicians in surgical 
specialties declined 4 percent, from $11,981 billion to $11,491 billion. 

Understanding changes by specialty is somewhat complicated by the fact that in 1992 
Medicare carriers were encouraged to implement an expanded system of specialty 
designation codes. A study conducted for HCFA to examine this issue found that 4.5 
percent of the physicians changed or redesignated their specialty category around this 
period.^ Despite the potential for some distortions resulting from these coding changes, 
the data clearly indicate a shift in payments by specialty. 

Further support that the MFS is stimulating the kinds of changes intended is illustrated 
by Figure 2, which shows allowed charges by type of service.^ Figure 2 shows the abrupt 
shift in the distribution of allowed charges. In the first quarter of 1992, when the MFS 
went into effect, there was an immediate shift in the proportion of allowed charges that 
went for visits and consultations relative to the allowed charges for procedures. Figure 2 
also shows that these changes have persisted into 1993. 



^ These monitoring data for 1991 and 1992 are considered complete. Allowed charges are based on 
billings by physicians for all Part B services, not just services paid under the MFS. 

* Performed by the consulting firm HK Research (1993, July 29). 

' Appendix II provides information on the procedure/service classification system. 



Figure 1 

Total Allowed Charges 
by Specialty: 1991 and 1992 



in Millions 



(Percent Change) 



$15,000 



$10,000 - 



$5,000 - 



(13%) (3%) (-4%) 



(0%) 



(-14%) 



S12.204 $11,981. 




Primary Medical Surgical 0th Med All 

Care Specialty Specialty Specialty Other 

Specialty 



Dl991 11992 



SOURCE: HCFA Part B Monitoring System: HCFA National Claims History File. 
Prepared by: Office of Research and Demonstrations, HCFA. 



8 



Figure 2 

Allowed Charges - MFS Physician Services 

1990 to 1993, by Quarter 

All Medicare Beneficiaries 



Percent of Total Allowed Charges 



60% 



50%- 
40% -_ 

30%- 

20% -I 

,1 



■ ■ I 1 • 



II>^ 






>^ ^^ ^ ^ ^!^ ^ ^ ^1^ i^ ^. ^ ^ ?»^ ^1^ 7^ ?!*' 



1 0% - 



0% 



1234123412341234 
1990 I 1991 I 1992 | 1993 



-^VlBlts/Consults -r Procedures * Imagrng 



SOURCES: 1990 and 1991 - 5 percent BMAD; HCFA Part B Beneficiary Monitoring 
System for 1992 and 1993 (updated through December 1993). 



Prepared by: Office of Research and Demonstrations, HCFA. 



Detailed information about changes in Medicare allowed charges are provided in 
Tables 1-5 at the end of this report (see Appendices I and II also).^° Table 1 shows 
that total allowed charges for Part B fee-for-service claims (that is, excluding health 
maintenance organizations (HMOs)) increased only 2.4 percent between 1991 and 1992. 
Adjusted for the growth in population, the percent increase becomes only 0.7 percent.^^ 



Table 2 shows further details about the shifts in Medicare allowed charges, breaking out 
payments for physicians and non-physicians. These data show that Medicare Part B 
payments for non-physician services, most of which are not included in the MFS, 
increased substantially from $8,008 billion in 1991 to $9,088 billion, a 13.5 percent 
increase. Most of these payments are in the "all other" category, which includes durable 
medical equipment. This table illustrates that if only allowed charges for physicians 
services are compared, there was an actual decline in Medicare allowed charges between 
1991 and 1992, from $34,906 billion to $34,854 billion - perhaps the first time this has 
occurred since Medicare began. 

Preliminary data for 1993 (physicians' billed services reported to HCFA through 
December 31, 1993) are shown in Table 3. These figures indicate that the share of 
allowed -charges for primary care and medical specialties continues to increase, with 
corresponding declines in the surgical specialties. Thus, the preliminary 1993 data 
suggest that the changes intended by implementing the fee schedule legislation are 
continuing. 

Table 4 provides patterns of allowed charges by the place (site) where care was received. 
There has been a continued decline in the proportion of Part B allowed charges for 
services in the hospital inpatient setting (reflecting in part the decline in surgical 
procedure allowed charges). These declined from 40.1 percent in 1991 to 35.6 percent in 
the preliminary data for 1993. The decline also reflects, in part, the shift to the 
outpatient setting for some procedures. This trend has been noted in earlier studies of 
the impact of the Medicare hospital prospective payment system. 

Table 5 provides further details on changes in allowed charges for procedures between 

1990 and 1993. Between 1990 and 1991, allowed charges increased 8.8 percent; between 

1991 and 1992, allowed charges declined 9.5 percent. (Because data for 1993 are 
preliminary, the percent change was not computed.) As shown, allowed charges for 
nearly every procedure declined between 1991 and 1992. 



'° These allowed charge estimates for 1991 and 1992 may differ from HCFA's actuarial estimates for 
several reasons, including differences in scope of services examined and the time period used in the 
calculations. 

" The magnitude of these increases reflect, in part, the approximately 3 percent reduction in 1992 
payments for MFS services resulting from the baseline adjustment applied in developing the 1992 
conversion factor. 



10 



As noted earlier the implementation of the MFS was expected to invoke a number of 
changes by area. For an analysis of the impact of the MFS by State see Appendix I. 

In summary, changes in allowed charges by type of service, by physician specialty, and by 
site of care provide strong indications that the MFS stimulated the kinds of changes that 
were intended and expected. The next section addresses the impact of the MFS on 
access to care. 

B. Has the MFS presented new barriers to access for vulnerable populations? 

This issue is central to this report and is explored using the five access measures 
discussed in Part 1. An important related question is whether the MFS reduced barriers 
to care for vulnerable populations. 

At the outset, it should be noted that most of the findings that are presented next cannot 
directly address the impact of the MFS on increasing or reducing access to care. For 
some of the studies, only baseline data were available at the time this report was being 
prepared; for other analyses, data are available for only a single point in time before the 
MFS was introduced. And, for the analysis of the influenza vaccine, only post-MFS 
data can be examined because the service was not covered in the period preceding the 
MFS. Nonetheless, despite these imperfect time series, all of these analyses add depth 
to our understanding of access to care for vulnerable population groups. 

Access measure 1: Use of ambulatory visits. One of the most important 
indicators used to track access to care is the rate of physician visits per person. This is 
considered an important measure because it is seen as an indicator of gaining entrance 
to the health care system. (When data are shown from the Part B monitoring system, 
rates can be given on a quarterly basis; when survey data are used, only annual rates are 
given.) 

Figures 3-7 illustrate the findings from the surveillance of ambulatory physician visits for 
five vulnerable subgroups of the Medicare population. Ambulatory visits include office, 
emergency room, home and nursing home visits as well as some specialty services. 

Figure 3 shows quarterly ambulatory visit rates for three age groups in the population 65 
years of age and over. All three age groups showed sunilar trends from 1990 through 
the first half of 1993, indicating that, to date, persons 85 years of age and over have not 
faced any new barriers to care under the MFS. 

Figure 4 shows trends by race. While ambulatory visit rates each quarter were 
consistently higher for white beneficiaries compared to black beneficiaries, the MFS does 
not appear to have increased the differences that already existed before the MFS went 
into effect However, it is clear that research needs to be done to understand whether 
the differences shown in ambulatory visit rates reflect primarily barriers by race or 
barriers by socioeconomic status. 



11 



Figure 5 shows ambulatory visits for four broad geographic groupings: beneficiaries 
residing in (1) core counties of metropolitan areas of 1 million or more population; (2) 
other metropolitan counties; (3) areas adjacent to metropolitan areas; and (4) areas 
nonadjacent to metropolitan areas. The highest visit rates are for beneficiaries residing 
in metropohtan areas. The lowest visit rates are for beneficiaries in non-metropolitan 
areas, whether or not they are adjacent to metropolitan areas. A comparison of these 
rates indicates that over time, the disparity increased slightly in 1991 and 1992. 
However, in the first two quarters of 1993 the disparity lessened a little. 

Figure 6 shows ambulatory visit rates for areas expected by 1996 to have had (1) the 
largest decreases in average prices (10-20 percent); (2) "no change" (within plus or minus 
3 percent); (3) moderate decreases (4-9 percent); and (4) largest increases 
(4-12 percent). As shown, ambulatory visit rates continue to be highest in areas 
expected by 1996 to have had relatively large decreases in allowed charges, indicating 
that the MFS to date has not presented barriers to care in these areas. 

Figure 7 shows trends in ambulatory visit rates for Dade County (Florida), Los Angeles 
County (California), and Manhattan (New York). These three metropolitan areas are 
expected to have had the largest decreases in prices by 1996. Compared to national use 
rates, residents, of Dade County had 62 to 68 percent more ambulatory physician visits 
per 1,000 throughout the 1990 to 1993 time period. Similarly, residents of Los Angeles 
County maintained use rates at about 40 percent over the national average. Use rates in 
Manhattan were about 33 to 37 percent higher than nationally in 1990 through 1992. 
However, in the first half of 1993, these rates dropped slightly to 27 percent over the 
national average. Further trend data will be necessary to determine if this is a short 
term deviation or a change in patterns of use. 

To monitor access to physicians' care for several other vulnerable populations, the 
Center for Health Economics Research (CHER) linked Medicare data with 1990 census 
data and with information on health professional shortage areas. Table 6 at the end of 
this report shows details from that analysis for 1991. At the time this report was being 
prepared, the analysis of changes between 1991 and 1992 was not yet completed. 
However, the findings for 1991 show that persons residing in areas designated as health 
professional shortage areas had lower outpatient visit rates compared to those not living 
in shortage areas. Persons living in poor areas (particularly, poor rural areas) had lower 
outpatient visit rates than those living in nonpoor areas while rural residents tended to 
have lower visit rates in general (except for emergency room visits) compared to urban 
residents. We will continue to analyze these patterns in the next report 

To track access to care for beneficiaries without supplemental insurance, the National 
Health Interview Survey (NHIS), sponsored by the National Center for Health Statistics, 
was used. Figure 8 shows average annual number of visits for beneficiaries with 
Medicare coverage only, compared to those with Medicare and private supplemental 
health insurance coverage. Each year, from 1984 through 1990 (the latest data available 
for this analysis), persons without supplemental policies have had fewer physicians' visits 



12 



Figure 3 

Ambulatory Physician Visits per 1,000 Persons 

1990 to 1993, by Quarter, by Age 

Medicare Beneficiaries Ages 65 and over 



VlslU per 1,000 Persons 



a.200- 



2.700- 



2.200- 



1.700 - 



1.200 




•^65 to 74 +75 to B4 *eS + 



Figure 4 



Ambulatory Physician Visits per 1,000 Persons 

1990 to 1993, by Quarter, by Race 

Medicare Beneficiaries Ages 65 and over 



visits per 1,000 persons 



2.400 ■ 




I —White -I- Buck 



SOURCES: 1990 and 1991 - 5 percent BMAD; HCFA Part B Beneficiary Monitoring 
System for 1992 and 1993 (updated through December 1993). 

Prepared by: Office of Research and Demonstrations, HCFA. 



13 



visits per 1,000 Persons 




Figure 5 

Ambulatory Physician Msits 

per 1,000 Persons 

by Population Density, by Quarter 



r 



-^Metro, Large Core -rMetro, Other -TR-Non Metro. Ad| ♦Non Metro. Non Ad| 



Visits per 1 ,000 Persons 



2.400 




Figure 6 

Ambulatory Physician Visits 

per 1,000 Persons 

by Ex Ante Impact Area, by Quarter 



""Increase ~rNo Change '^Moderate Decrease '*' Large Decrease 



Visits per 1,000 Persons 




Figure 7 

Ambulatory Physician Visits 

per 1,000 Persons 

by County, by Quarter 



'''National "TManhatian 'TtrOade County '*' Los Angeles 



SOURCES: 1990 and 1991 - 5 percent BMAD; HCFA Part B Beneficiary Monitoring System for 
1992 and 1993 (updated through December 1993). 

Prepared by: Office of Research and Demonstrations, HCFA. 



14 



Figure 8 

Physician Visits per Person per Year 
by Insurance Coverage: 1984 tlirough 1990 




1984 



1986 



1989 



LJ Medicare Only ■ Medicare and Other 



1990 



SOURCE: National Health Interview Survey, National Center for Health Statistics. 
Prepared by: Office of Research and Demonstrations, HCFA. 



15 



than persons with supplemental polices - even though the NHIS shows that persons 
without supplemental policies have had consistently greater levels of activity limitations. 
Over time, these differences in utilization have not declined. These findings support the 
hypothesis that Medicare beneficiaries without additional insurance coverage face 
barriers to care from out-of-pocket costs. At the same time, Medicare beneficiaries with 
additional coverage may be receiving unnecessary services. Table 7 at the end of this 
report and Appendix VI provide additional details from the NHIS. 

Table 7 also provides information over the period 1984-90 about the role health 
insurance plays in eliminating barriers to care for the general population aged 18-64 who 
are not on Medicare. Compared to those with health insurance, fewer of the uninsured 
had a physician visit during the year. The mean number of visits per person per year 
was lower and this pattern has not improved over time. In 1990, in the age group 18-64, 
only 60 percent of the uninsured saw a physician compared to 75 percent of the privately 
insured, even though the uninsured had higher rates of activity limitations (see 
Appendix VI). 

Access measure 2: Percent with a health problem and not receiving care. One of the 
most direct indicators of access to physicians' care is having a health problem and not 
receiving care.- Figure 9 shows data from the Medicare Current Beneficiary Survey 
(MCBS) for 1991 and 1992 for both the aged and disabled under Medicare. Compared 
to beneficiaries 65 years of age and over, the disabled had a higher proportion of 
persons who reported having a health problem but not receiving any care in the previous 
year. This finding is consistent with the fact that the disabled population are more likely 
than the aged to face greater barriers to care because of more chronic illnesses and 
continuing care needs. 

Figure 9, however, indicates improvement for both population groups for this indicator 
during the two-year period. (Because the MCBS began in 1991, we do not have enough 
data to determine if these findings are part of an improving trend or if they can be 
associated with the introduction of the MFS.) Table 8 at the end of this report and 
Appendix V show further details from this study. In particular, it shows that patient 
satisfaction generally increased for both the aged and disabled along four dimensions: 
quality of medical care; availability of medical care; ease of getting to a physician; and 
costs. 

Access measure 3: Use of preventive services. Medicare covers four preventive services: 
pneumococcal pneumonia and influenza vaccines, Pap tests, and mammography. The 
CHER study of vulnerable Medicare populations cited earlier traced the use of three of 
these preventive services. 

Figure 10 shows differences in the rate of mammography use for 1991. It is important to 
note that every vulnerable subgroup identified in the study had lower rates of use of 
mammograms than Medicare beneficiaries overall. 



16 



Figure 9 

Percent of Persons Reporting a Health Problem 
and Not Receiving Care in Previous Year 



25.0% 



20.0% 



15.0% - 



10.0% - 



5.0% - 



0.0% 



Aged 



Disabled 



8.1% 




22.8% 




1991 1992 



1991 1992 



SOURCE: Medicare Current Beneficiary Survey, Round 1 and Round 4 Data; 
Medicare NCH Claims for MCBS Population 

Prepared by: Office of Research and Demonstrations, HCFA. 



17 



Figure 10 

Mammography Use 

for Vulnerable Population Groups: 1991 

Rate per 1,000 Persons 



400 



300- 



200 - 




100- 



Total 



Shortage Poverty Black Medicaid Disabled 85-t- Rural 

Area Area 



SOURCE: Part B Claims and denominator file for a sample of Medicare 
Beneficiaries: 1991 

Prepared by: Office of Research and Demonstrations, HCFA. 



18 



Table 9 at the end of this report provides some preliminary information from Medicare 
administrative data on the use of the influenza vaccine, which became a covered service 
in 1993. Two HCPCS codes are used to bill for this service: one for administration and 
the other for the vaccine itself. At the time this report was being prepared, records were 
available for the administration component only. Although influenza immunizations are 
likely to be undercounted by as much as 50 percent, an examination of the billings for 
administration only is instructive (see Table 9). Among the aged and disabled 
populations, differences in the rate of influenza immunizations were striking, with rates 
for black beneficiaries less than half those for white. When complete data are available 
for 1993, the rates for both groups are expected to be considerably greater, but it is very 
likely that large differences by race will still be found. 

Table 10 of this report provides further information for 1991 on Pap tests and the 
pneumococcal pneumonia immunizations from the special study by CHER. For Pap 
tests, rates were dramatically lower for black beneficiaries, for the dually eligible, and for 
persons living in health professional shortage areas and in poor areas. For 
pneumococcal pneumonia immunization, rates were also lower for these vulnerable 
groups, except for those residing in HPSAs.^^ 

These data4)rovide evidence that the vulnerable population groups we have identified 
are at-risk of not receiving covered preventive services ~ services that were included 
under Medicare to make them affordable to all. 

Access measure 4: Hospitalizations for ambulatory care sensitive conditions. The 
special study by CHER examined hospitalization rates for 24 conditions that experts 
identified as ambulatory care sensitive (ACS) conditions (see Appendk IV). Patients 
with these conditions are considered to be at increased risk of hospitalization for these 
conditions if they are without appropriate and continuing ambulatory care. Higher 
hospitalization rates for these conditions are seen as indicators that there may be 
barriers to care. 

Figure 11 shows the combined hospital admission rate in 1991 for these 24 conditions for 
the vulnerable groups that were studied. In 1991, the national rate was 61.4 admissions 
per 1,000 beneficiaries. Each of the vulnerable groups studied had higher rates of 
hospitalizations. 

Table 11 at the end of this report provides further details about hospitalization rates for 
ACS conditions. The table shows rates of hospitalization for four specific Ambulatory 
Care Sensitive conditions (bacterial pneumonia, asthma, congestive heart failure, and 
diabetes with complications) and the rate for all 24 ACS conditions, combined. For all 
24 ACS conditions combined, admission rates were significantly higher for all of the 



'^ These differences are difficult to evaluate fully at this time for several reasons, Including the 
incompleteness of Medicare administrative data. See Appendix IV for additional explanations. 



19 



Figure 11 

Ambulatory Care Sensitive Admission Rates 

for Vulnerable Population Groups: 1991 

Rate per 1,000 Persons 



150.0 - 



100.0 



50.0 - 



0.0 




Total 



Shoiiag* Povarty Black Madleald Dlaablad 86-)- Rural 

Araa Araa 



SOURCE: Part A Claims and denominator file for a sample of Medicare 
Beneficiaries: 1991 

Prepared by: Office of Research and Demonstrations, HCFA. 



20 



vulnerable groups, except for residents of rural health professional shortage areas. The 
differences in the absolute magnitude of the rates are often very large. The hospital 
admission rate for beneficiaries living in poor urban areas (88.2 admissions per 1,000 
enroUees) was almost 50 percent greater than the rate for beneficiaries in nonpoor areas 
(59.9 admissions per 1,000). 

It is important to consider that beneficiaries living in poor urban areas had nearly a 
50 percent higher rate of admissions for ACS conditions, even though their outpatient 
physician visit rate was not lower than the rate for beneficiaries living in nonpoor areas. 
Similarly, Medicaid eligible beneficiaries had higher rates of hospital admissions for ACS 
conditions even though their outpatient visit rate was higher than those not on Medicaid 
(Table 6). These findings suggest that Medicare beneficiaries who live in poor areas or 
are eligible for Medicaid are hkely to be in poor health and may need more continuous 
and appropriate ambulatory care if they are to avoid hospitalizations for these ACS 
conditions. 

Access measure 5: Referral sensitive procedure rates. For this measure, the analysis 
focuses on one vulnerable subgroup ~ black beneficiaries.^^ Figure 12 shows procedure 
rates for coronary artery bypass graft (CABG) and percutaneous transluminal coronary 
angioplasty-(PTCA) in 1991 and 1992 for black and white beneficiaries. For each of 
these procedures, the rate for white beneficiaries was substantially higher both years, 
although the ratio of the rate for black beneficiaries to the rate for white beneficiaries 
increased in 1992 over 1991, indicating that the gap has narrowed a little. 

Table 12 at the end of this report shows additional information about procedure rates in 
1990 and 1992 for 18 major procedures, based on Medicare hospital administrative data. 
These procedures were selected for their frequency, the lack of agreement about their 
outcomes and effectiveness, or their costliness. Included are newer, referral sensitive 
procedures, such as PTCA, CABG surgery, and total knee replacement (TKR) and 
traditional procedures, such as appendectomy and inguinal hernia repair. Rates of these 
procedures, as well as their 30-day post-admission death rate, are shown. 

In 1990 and 1992, for each of the 18 procedures being monitored, the rate for black 
beneficiaries was lower than for white beneficiaries, although the disparities vary 
according to the procedure. As an example, for total knee replacement in 1990, the 
ratio of the rate for black beneficiaries compared to white beneficiaries was only 0.62, 
while for prostatectomy the corresponding ratio was 0.91. 

In 1992, the first year that the MFS was in effect, the rate of the heart and vascular 
procedures increased for both races; this was also true for the orthopedic and back 



" The only other vulnerable subgroup that can be identified in this analysis is beneficiaries residing in 
rural areas. Procedure rates have not been found to be consistently higher or lower for rural residents 
compared to those residing in MS As. 



21 



Figure 12 

Heart and Vascular Procedures 
Rate per 1,000 Beneficiaries, by Race 



CABG 



PTCA 




1990 



1992 



1990 



I White D Black 



1992 



SOURCE: Data from HCFA's BDMS MEDPAR files. 



Prepared by: Office of Research and Demonstrations, HCFA. 



22 



procedures. For most of these procedures, the rate for black beneficiaries increased 
more than for white beneficiaries. 

Except for the procedures performed for hip fracture, the 30-day post-admission death 
rates continued to be higher for black beneficiaries than for white beneficiaries. This 
may indicate, that on average, black beneficiaries who undergo these procedures are 
more severely ill than white beneficiaries. There also may be differences in the quality 
of care between the two groups. (See Appendix III for additional information.) 

The preponderance of evidence relating to access to these hospital procedures indicates 
that the MFS created no new barriers by race. This finding is perhaps even more 
heartening in light of the findings that in 1992, under the MFS, total allowed charges 
were lower than in 1991 for nearly all of the procedure groups being monitored (see 
Table 5). Nonetheless, substantial differences by race continue to exist in the use of 
these procedures. 

In summary, the monitoring of these five access measures shows no evidence to-date that 
the MFS has raised new barriers to physicians' care. However, these analyses suggest 
that there are persistent problems ~ with varying facets to them - relating to access to 
physicians'-care for many of the vulnerable populations we have identified. (See 
Appendix V about perceptions of barriers, satisfaction with care, and attitudes toward 
the usual source of care.) 

C. What have been the impacts of the MFS on physicians' practices? 

Two studies are ongoing to monitor changes in physicians' practices and supply. The 
first study uses the Part B monitoring file that contains a sample of physicians. Linked 
to each physician are all of the Medicare claims for services provided by that physician. 
The study examined data for 1991 and 1992 for 18 States and focused on a number of 
key issues, in particular determining changes that may have occurred in the number of 
Medicare patients treated and in average allowed charges. 

Figure 13 illustrates changes in average allowed charges per physician by specialty 
between 1991 and 1992. For primary care specialties, average allowed charges per 
physician between 1991 and 1992 increased 10 percent, from $37,362 to $41,039. The 
increase was 2 percent for medical specialties, from $111,686 to $114,041. For physicians 
in surgical specialties average allowed charges per physician fell 3 percent, from $97,020 
to $94,082. 

Tables 13 and 14 show additional information from this study. Mean Medicare caseload 
for the 7,361 physicians in the sample and changes in caseload between 1991 and 1992 
are shown in Table 13. As might be expected. Medicare caseload varied considerably by 
specialty of the physician. In 1991, the average number of patients per physician for 
primary care physicians was 277 patients, for limited licensed practitioners, 118 patients, 
and for radiologists, 1,373 patients. The mean caseloads for most specialties increased 



23 



Figure 13 

Mean Allowed Charges per Physician 
by Specialty: 1991 and 1992 



Percent Change 



$140,000- 

$120,000 - 

$100,000- 

$80,000 - 

$60,000 

$40,000 - 

$20,000 - 

$0 



10% 



$37,362 



$41,039 




Primary Care 
Specialty 



2% 



$111,686 «"*'0*1 



Medica 
Specialty 




Dl991 11992 



-3% 



$97,020 



$94,082 




Surgical 
Specialty 



SOURCE: HCFA Part B Monitoring System: HCFA National Claims History 
Physician Sample File. 

Prepared by: Office of Research and Demonstrations, HCFA. 



24 



(between 1991 and 1992). Surgery specialists treated on average 5 percent more patients 
and primary care physicians treated 4 percent more. (See Appendix VIII for the 
complete study.) 

Physician supply is also being monitored, in terms of physician to population ratios, by 
specialty and by geographic area (see Appendix VII). Although Medicare payment 
reform is not likely to affect the supply of physicians for several years to come, if at all, 
it is still valuable to understand current supply trends because they affect access to and 
utilization of services. Table 15 shows trends in the number of primary care and medical 
specialists per 100,000 Medicare beneficiaries for metropolitan and nonmetropolitan 
areas. 

4 

As expected, the ratio of primary care and medical specialists per 100,000 beneficiaries is 
considerably higher in metropolitan areas compared to nonmetropolitan areas. 
Moreover, differences increased during the entire 1984-92 period. In 1984, the physician 
to population ratio in metropolitan areas was 162 percent higher than in 
nonmetropolitan areas (385 per 100,000 and 1,010 per 100,000, respectively). By 1992, 
this difference had increased to 191 percent, indicating a pressing need to continue to 
monitor the supply of physicians across geographic areas. 

PART 3. DISCUSSION and CONCLUSIONS 

OBRA 1989 requires the Secretary of the Department of Health and Human Services to 
include as part of this annual Medicare physician payment report recommendations: 

(i) addressing any identified patterns of inappropriate utilization, 

(ii) on utilization review, 

(iii) on physician education or patient education. 

(iv) addressing any problem of beneficiary access to care made evident by the 
monitoring process, and 

(v) on such matters as the Secretary deems appropriate. 

This report also provides an overview of the extensive activities in HCFA and in the 
Agency for Health Care Policy and Research (AHCPR) to address patterns of 
inappropriate utilization, utilization review, and physician and patient education (see 
Appendix IX). AHCPR's medical treatment effectiveness program (MEDTEP) and 
HCFA's peer review organizations (PRO) program are expected to result in more and 
better knowledge about effective treatments to help guide physicians and patients to 
select the most appropriate, effective, and efficient care. Toward this end, a Federal 
workgroup has been established that includes AHCPR and HCFA along with 



25 



representatives of the Department of Veterans Affairs and the Department of Defense 
to support the current efforts to improve medical review methods and procedures. 

With regard to the statute's iv and v (above) the following conclusions are offered. 

Conclusions 

From the broad perspective taken for monitoring utilization and access to care for this 
report, as well as our knowledge of the Medicare program and other survey data, there 
are five principal conclusions that can be drawn: 

1. The Medicare physician fee schedule has produced the kinds of shifts in payments 
that were anticipated, by type of service, physicians' specialty, and geographic 
area. In particular, the introduction of the fee schedule was accompanied by a 
relative increase in allowed charges for visits and consultations and a relative 
decrease in allowed charges for procedure-based services. 

2. For the vulnerable populations studied, no new barriers to care were found 
although there are clear indications that many population groups continue to face 
barriers to care. 

The kinds of the studies described in this report will be updated with more recent 
data for the next report. It is expected that new analyses will also be undertaken 
to provide additional insights. For example, there are plans to link 1990 zip code 
level socioeconomic data from the Census Bureau with Medicare administrative 
data. The linked data will be used to aggregate areas by socioeconomic status 
(SES) to analyze whether differences in utilization of certain procedures signify 
racial barriers or barriers related to SES. 

3. Improved health insurance coverage is an important factor in increasing access to 
care. 

The history of the Medicare program shows that the enactment of Medicare went 
a long way toward providing access to physicians' and hospital services for the 
elderly population in the Nation. In 1967, the first full year of the Medicare 
program. Medicare data show that beneficiaries of races other than white were 
only 71 percent as likely to be admitted for hospital services as white 
beneficiaries. Over time, the hospital discharge rate for black beneficiaries 
reached the same level as that for white beneficiaries. Presently, the hospital 
discharge rate for black beneficiaries is about 10 percent greater than for white 
beneficiaries. This trend suggests that many of the barriers to physicians' and 
inpatient hospital care have declined. 

Based on the NHIS, which is used in this report to compare patterns and trends 
in the Medicare population with those found in the population under age 65, the 



26 



analyses show that health insurance coverage is an important factor in providing 
access to care for persons of all ages. Other National surveys also confirm that 
there is a consistent relationship between insurance coverage and access to health 
care. Taken together, our National surveys and the Medicare experience suggest 
that efforts to improve health insurance coverage for persons under age 65 will 
very likely go a long way toward ameliorating problems relating to access to care. 

4. Additional understanding is needed of barriers to care for vulnerable populations 
in order to further improve their access to care. 

As observed throughout this report, even with Medicare coverage, problems exist 
for vulnerable subgroups. Black Medicare beneficiaries, for example, have 
substantially lower rates of use of the newer procedures performed in the hospital 
(such as CABG and hip and knee replacements) compared to white Medicare 
beneficiaries. At the same time, a number of vulnerable subgroups were found to 
have higher hospital admission rates for ambulatory-care sensitive conditions 
(such as asthma and bacterial pneumonia) compared to non-vulnerable groups. 
Thus, we believe that addidional understanding is needed of barriers to care for 
vulnerable subgroups if we are to further improve access to care for these 
populations. 

5. Effective monitoring of access to care requires the development of more sensitive 
measures of access as well as better data sets and linkages to other information. 

Understanding differences in utilization of health care services requires increased 
information about health status and about the incidence and prevalence of illness 
across population groups and reliable and ongoing data systems to monitor access 
to care. 

Summary 

In summary, the implementation of the Medicare fee schedule is associated with the 
types of payment changes expected; there is no evidence that the implementation of the 
Medicare fee schedule resulted in new barriers to care. Moreover, our 1993 Report to 
Congress entitled, "Changes in Physician Participation, Assignment, and Extra Billing in 
the Medicare Program During Calendar Year 1992," showed that during the first year of 
the Medicare fee schedule the assignment rate increased; and on unassigned claims, the 
extra billing amounts decreased (HCFA, 1994). There are no recommendations to offer 
at this time. 



27 



ACKNOWLEDGMENTS 

This report was prepared in the Office of Research and Demonstrations (ORD), Health 
Care Financing Administration (HCFA), under the general direction of 
George Schieber, Ph.D., Director, Office of Research and Demonstrations and 
Steven Clauser, Ph.D., Acting Director of the Office of Research. Marian Gomick, 
Director of the Division of Beneficiary Studies, ORD, and WilUam Sobaski, Director of 
the Division of Reimbursement and Economic Studies, ORD, were responsible for the 
overall design and technical oversight of the individual analyses. The individual analyses 
were prepared by HCFA staff except for two prepared under a cooperative agreement 
with tiie Center for Health Economics Research by Margo Rosenbach, Ph.D., 
Janet Mitchell, Ph.D., Rezaul Khandker, Ph.D., and Monika Reti. Individual HCFA 
analyses were prepared by William Sobaski; Ann Meadow, Sc.D.; Paul Eggers, Ph.D.; 
Marshall McBean, M.D.; Leslye Fitterman; Lawrence Kucken; Joan Warren, Ph.D.; and 
Renee Mentnech. Computer systems analysis and programming support were provided 
by Marilyn Newton, Ronald Prihoda, Mae Robinson, and Lynne Rabey in the Bureau of 
Data Management and Strategy. Julie Schoenman, Ph.D., and Keith Umbel from 
Project HOPE prepared the data file used for the analysis of the supply of physicians. 
Gary Olin, Ph.D., Suzanne Benner, Susan Thomas, and Young Park of Fu Associates 
provided analytic and programming support for the analysis of the National Health 
Interview Survey. Data support was also provided by Benson Dutton and Daniel Babish, 
OkD. Statistical advice for the analysis of the national Claims History Physician Sample 
File was provided by James Beebe. Several individuals provided review and comments 
including Sherry Terrell, Ph.D., James Lubitz, Harry Savitt, Ph.D., Alma McMillan, and 
Maria Friedman, D.B.A. 

This report, summarizing the individual analyses, was written by Marian Gomick. 
Paul Eggers prepared the figures. Cheryl Hickman was responsible for the preparation 
of the manuscript. 



28 



BIBLIOGRAPHY 



Aday L.A., G. Fleming, R. Andersen. (1984). Access to Medical Care in the U.S.: Who 
has it Who Doesn't? Chicago: Pluribus Press Inc. and the University of Chicago. 

Ayanian, J.Z. and Epstein A.M. (1991, July 25). Differences in the Use of Procedures 
Between Women and Men Hospitalized for Coronary Heart Disease. New England 
Journal of Medicine 325:221. 

Berenson, R. and J. Holahan. (1990, December). "Using a New Type-of- Service 
Classification System to Examine the Growth in Medicare Physician Expenditures." 
Washington, D.C.: The Urban Institute, Pub. No. 3983-01. Available from NTIS, 
accession No. PB91-188599. 

Council Report. "Black- White Disparities in Health Care." (1990). Journal of the 
American Medical Association 263 (17): 2344-2346. 

Federal Register : 56(227) :596 18-59620, November 25,1991. 

Health Care Financing Administration. (1994, January 7). 1993 Annual Report to 
Congress - Changes in Physician Participation, Assignment, and Extra Billing in the 
Medicare Program During Calendar Year 1992. 

Health Care Financing Administration. (1993, May 6). 1993 Annual Report to 
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Medicare Services . 

Health Care Financing Administration. (1992, May 21). 1992 Annual Report to 
Congress - Monitoring Changes in Use of. Access to, and Appropriateness of Part B 
Medicare Services . 

Health Care Financing Administration. (1991, May 2). 1991 Annual Report to Congress 
- Monitoring Changes in Use of. Access to, and Appropriateness of Part B Medicare 
Services . 

Health Care Financing Administration. (1990, June). Special Report Volume 2. 
Hospital Data by Geographic Area for Aged Medicare Beneficiaries: Selected 
Procedures. 1986 . HCFA Pub No. 03300. 

Health Care Financing Administration. (1990, June). Special Report Volume 3. 
Rehospitalization by Geographic Area for Aged Medicare Beneficiaries: Selected 
Procedures. 1986-87. HCFA Pub No. 03303. 



29 



Hewitt, M. (1989, July). Defining "Rural" Areas: Impact on Health Care Policy and 
Research, OTA Staff Paper, Washington, D.C.: U.S. Government Printing Office. 

HK Research Corporation. (1993, July 29). Report on Changes in Classification of 
Physician Specialty. Cooperative Agreement No. 17-C-90 159/3-02. Sevema Park, MD. 
NTIS Accession No. PB-94- 152089. 

Holahan, J., and S. Zuckerman. (1991, September). "Geographic Variation in the 
Volume and Intensity of Medicare Physician Services: A Descriptive Analysis. 
Washington, D.C.: The Urban Institute, Pub. No. 3983-06. Available from NTIS, 
accession No. PB92-227214. 

Holahan, J. et al., "Trends in Access to Physician Services" Urban Institute Policy Center 
task, in progress. 

Institute of Medicine (U.S.). (1990). Committee to Design a Strategy for Quality 
Review and Assurance in Medicare. Medicare: A Stragegv for Qualitv Assurance : 
Kathleen N. Lohr, editor. Washington, D.C.: National Academy of Sciences. National 
Academy Press. 

Institute of Medicine (U.S.). (1993). Committee on Monitoring Access to Personal 
Health Care Services. Access to health care in America : Michael Millman, editor. 
Washington, D.C.: National Academy of Sciences. National Academy Press. 

Physician Payment Reform Commission. (1992, June 2). PPRC's Comments on the 
Secretary of Health and Human Services' 1992 Report on Access Washington, D.C.: 
PPRC. 

Physician Payment Reform Commission. (1993). Annual Report to Congress . 
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U.S. Congress, Office of Technology Assessment. (1990, September). Health Care in 
Rural America. OTA-H-434 (Washington, DC: U.S. Government Printing Office). 

Zuckerman S., Miller, M., and Wade, M. (1993, February). "Regional Variations in the 
Impact of Medicare Physician Payment Reform" Washington, D.C: The Urban 
Institute, Pub. No. 6192-07. 



30 



Tabk 1. Medicare Part B fee-for -service claims: Allowed charges by type of service, 1991 and 1992 





Total 

$43,942 
42,916 


Medical Visits 

and 

Consultations 


Surgery, 
Rad. Ther., 
Anesthesia 
& Assistants 


X-ray 
and 
Lab 
Tests 


All 
Other 


Year 

1992 
1991 




$14,926 
13,885 


Allowed charges (in 

$13,301 
14,116 


millions) 

$8,785 
8,727 


$6,930 
6,186 


Percent change 
OvCTall 


2.4 




7.5 


-5.8 


0.7 


12.0 


Adjusted 
for Changed 
Population 


0.7 




5.7 


-7.3 


-1.0 


10.2 



Sources: - HCFA Part B Monitoring System: Allowed charge from HCFA National Claims History File. 

- Population information from June 30 Medicare Part B Enrollment Files. 
Prepared by : Office of Research and Demonstrations. HCFA. 



31 



Table 2. Medicare Part B fee-for -service claims: Allowed charges by type of service and physician/supplier specialty 
category, 1991 and 1992 



Total 
Non-Physician 

Supplier 

Facility/Lab 

Practitioner 

Physician 

Primary Care 
Specialties 

Medical Specialty 
Surgical Specialty 



Other Medical 
Specialty 

Clinic/Unknown 



Chiropractor, Optometrists 
& Podiatrists 



Year 



Total 



1992 


$43,942 


1991 


42,915 


1992 


9,088 


1991 


8,008 


1992 


5,668 


1991 


5.021 


1992 


2,886 


1991 


2.557 


1992 


534 


1991 


430 


1992 


34,854 


1991 


34.906 


1992 


3,376 


1991 


2,976 


1992 


12.616 


1991 


12^04 


1992 


11,491 


1991 


11,981 


1992 


4.960 


1991 


4,942 


1992 


1,244 


1991 


1,680 


1992 


1,167 


1991 


1,123 



Surgery X-ray 

Medical Visits Rad. Ther., and 

and Anesthesia Lab 

Consultations & Assistants Tests 



Allowed charges (in millions) 



All 
Other 



$14,926 
13.885 


$13,301 
14.116 


$8,785 
8,727 


$6,930 
6,186 


153 
230 


351 
361 


2370 
2,051 


6,214 
5366 


63 
42 


20 
12 


167 
193 


5.418 
4,774 


28 
137 


51 
103 


2,192 
1,848 


615 
469 


62 
51 


280 

246 


11 
10 


181 

123 


14,773 
13,655 


12,951 
13375 


6,415 
6,676 


715 
820 


2,658 
2,237 


232 
227 


459 
479 


27 
33 


7,879 
7,275 


1.982 
2.123 


2,233 
2,291 


522 
515 


2,835 
2.620 


7.978 
8,651 


631 
605 


47 
105 


155 
145 


1,973 
1,867 


2,792 
2,875 


40 
55 


620 
800 


329 
453 


259 
378 


36 
49 


625 
577 


457 
432 


42 
48 


43 
66 



Source: HCFA Part B Monitoring System: HCFA National Claims History File. 
Prepared by: Office of Research and Demonstrations, HCFA. 



32 



Table 3. Medicare Part B fee-for -service claims: Allowed charges by physician specialty category: 1991, 1992, and 
preliminary 1993 





Allowed 




Charges 




(millions) 


All Physicians 




1993 preliminary 


532,040 


1992 


34,854 


1991 


34,906 


Primary Care Specialties 




1993 preliminary 


3332 


1992 


3376 


1991 


2,976 


Medical Specialties 




1993 preliminary 


11,989 


1992 


12,616 


1991 


12,204 


Surgical Specialties 




1993 preliminary 


10,442 


1992 


11,491 


1991 


11,981 


Other MD Specialties 




1993 preliminary 


4.297 


1992 


4,960 


1991 


4.942 


Clinics/Unknown 




1993 preliminary 


902 


1992 


1,244 


1991 


1,680 


Chiropractors, Optometrists, and Podiatrists 




1993 preliminary 


1,078 


1992 


1.167 


1991 


1,123 



Percent 
of Total 



100.0 
100.0 
100.0 



10.4 
9.7 
8.5 

37.4 
36.2 
35.0 

32.6 
33.0 
34.3 

13.4 
14.2 
14.2 

2.8 
3.6 
4.8 

3.4 
33 
3.2 



Source: HCFA Part B Monitoring System: HCFA National Claims History File. 
Prepared by: Office of Research and Demonstrations, HCFA. 



33 



Table 4. Medicare Part B fee-for-service claims: Allowed charges for physician services by place of service, 1991, 
1992 and preliminary 1993 





1991 






1992 


Preliminary 1993 


Place of Service 


Amount 
(millions) 


Percent 


Amount 
(millions) 


Percent 


Amount 
(millions) 


Percent 


AU 


$34,906 


100.0 


534,854 


100.0 


$32,040 


100.0 


Office 


13,677 


39.2 


13,940 


40.0 


13,791 


43.0 


Home 


158 


0.4 


146 


0.4 


117 


0.4 


Hospital Inpatient 


13,986 


40.1 


13,210 


37.9 


1U93 


35.6 


HOPDorER 


5,587 


16.0 


5,465 


15.7 


4,979 


15.5 


ASC 


493 


1.4 


669 


1.9 


698 


2.2 


Nursing Home 


518 


1.5 


677 


1.9 


649 


2.0 


Another 


488 


1.4 


747 


2.1 


413 


1.3 



Notes: HOPD = Hospital Outpatient Department 
ER = Emergency Room 
ASC = Ambulatory Surgical Center 

Source: HCFA Part B Monitoring System: HCFA National Qaims History File. 
Prepared by: Office of Research and Demonstrations, HCFA. 



34 



Table 5: Medicare Part B fee-for-service claims: Allowed charges for physician services covered by the Medicare fee 
schedule for procedures: 1990-1993 



Service category 



1990 



1991 



1992 



Allowed charges (in millions) 



1993 



1990-91 



1991-92 



Percent Change 



Total 



$13,902 $15,132 



$13,690 



$12,067 



8.8 



-9.5 



Major Procedure: General 


1,704 


1,690 


1,496 


1,273 


-0.8 


-11.5 


Breast 


70 


71 


59 


51 


1.4 


-17.6 


Colectomy 


182 


172 


148 


131 


-5.4 


-14.1 


Cholecystectomy 


142 


90 


62 


48 


-36.4 


-30.8 


TURP 


233 


221 


161 


132 


-5.1 


-26.9 


Hysterectomy 


45 


51 


53 


44 


14.4 


2.2 


Disk Surgery 


151 


170 


164 


146 


12.5 


-3.3 


Other 


881 


914 


848 


721 


3.7 


-7.2 


Major Procedure: Cardiovascular 


1,811 


1,890 


1,773 


1,553 


4.3 


-6.2 


CABG 


569 


549 


493 


424 


-3.5 


-10.2 


Aneurysm 


80 


76 


64 


57 


■4A 


-16.5 


Thromboendanereciomy 


76 


88 


81 


73 


15.8 


-8.4 


PTCA 


163 


220 


216 


188 


34.5 


-1.9 


Pacemaker 


130 


123 


110 


94 


-5.0 


-10.9 


Other 


793 


833 


810 


716 


5.0 


-2.8 


Major Procedure: Orthopedic 


1,009 


1,069 


1,001 


914 


5.9 


-6.3 


Hip Fracture Repair 


239 


245 


229 


202 


2.5 


-6.5 


Hip Replacement 


234 


239 


201 


180 


2.1 


-16.1 


Knee Revision 


242 


271 


262 


248 


11.9 


-3.3 


Other 


295 


314 


310 


284 


6.7 


-1.3 


Major Procedure: Eye 


2,527 


2,930 


2,530 


2,205 


15.9 


-13.7 


Corneal Transplant 


43 


45 


36 


32 


4.1 


-18.5 


Cat Rem/Lens Insen 


1,579 


1,813 


1,584 


1,351 


14.9 


-12.7 


Retinal Detachment 


66 


72 


59 


52 


8.3 


-17.7 


Treatm Retinal Lesions 


172 


188 


147 


155 


9.0 


-21.7 


Other 


667 


812 


704 


615 


21.8 


-13.4 


Ambulatory Procedures: 


1,164 


1,286 


1,144 


1,018 


10.5 


-11.0 


Skin 


446 


501 


452 


397 


12.2 


-9.8 


Musculoskeletal 


178 


199 


173 


150 


11.6 


-13.1 


Hernia Repair 


81 


77 


64 


59 


-5.4 


-16.3 


Lithotripsy 


22 


22 


20 


19 


-1.3 


-9.1 


Other 


436 


487 


435 


394 


11.8 


-10.7 


Minor Procedures: 


1,181 


1,348 


1,406 


1,336 


14.1 


4.3 


Skin 


586 


648 


699 


690 


10.5 


7.9 


Musculoskeletal 


178 


198 


190 


180 


11.4 


-4.4 


Other 


416 


502 


517 


465 


20.5 


3.1 


Oncology 


618 


719 


799 


710 


16.3 


11.1 


Radiation Therapy 


526 


600 


685 


590 


14.1 


14.1 


Other 


92 


119 


114 


120 


28.7 


-3.7 



35 



Table 5 (ConL): Medicare Part B fee-for-service claims: Allowed charges for physician services covered by the 
Medicare fee schedule for procedures: 1990-1993 



Service category 


1990 


Endoscopy 


1,442 


Arthroscopy 


67 


Upper GI Endoscopy 


382 


Sigmoidoscopy 


120 


Colonoscopy 


468 


Cystoscopy 


238 


Broncoscopy 


86 


Laparoscopic 




Cholecystectomy 


4 


Laryngoscopy 


38 


Other 


40 


Dialysis 


143 


Tests 


1,001 


Electrocardiograms 


618 


Cardiov Stress Tests 


144 


EKG Monitoring 


192 


Other 


48 


Anesthesia 


uoi 



1991 



1992 



1993' 



1990-91 



1991-92 



Allowed charges (in millions) 



1,657 
79 
442 
121 
497 
260 
94 

74 

42 

48 

164 

988 

590 

159 

185 

54 

1,392 



1,503 

76 

398 

98 

451 

238 

80 

76 

32 

54 

162 

572 

202 

207 

165 

68 

1,305 



1391 

74 

354 

82 

420 

223 

67 

83 
36 

53 
136 
411 
210 
157 
152 

75 
1,119 



Percent Change 


14.9 


-9.3 


18.6 


-3.7 


15.6 


-9.9 


1.0 


-19.1 


6.3 


-9.3 


9.1 


-8.5 


9.6 


-15.3 


Z,006.9 


2.1 


10.4 


-23.4 


20.4 


12.8 


14.2 


-1.0 


-1.3 


-42.2 


-4.5 


-65.8 


10.9 


29.9 


-3.2 


-10.7 


12.6 


25.9 


7.0 


-6.2 



^Preliminary data for 1993. 

Sources: 5 percent BMAD for 1990 and 1991; HCFA Part B Monitoring System (Updated through December 1993) for 1992 and 1993. 
Prepared by: Office of Research and Demonstrations, HCFA. 



36 



Table 6. Visits and consultations for vulnerable population groups, 1991 





Outpatient 
Visits 


ER Visits 


Home 
Visits 


Hospital 
Visits 


Nursing 

Home 

Visits 


Consultations 


Shortage Areas 

All 

Urban 

Rural 
Non-shOTtage 


4.72 ** 
4.91 ** 
4.43 ** 
5.12 


Age-sex adjusted 

0.38 ** 0.03 
0.42 ** 0.04 ** 
0.32 *• 0.02** 
0.31 0.03 


visits per beneficiary 

2.61 ** 0.30 
3.08 ** 0.34 ** 
1.87 ** 0.25 ** 
2.42 0.31 


0.41 ** 

0.49 ** 
028** 
0.40 


Poor Areas 

All 

Urban 

Rural 
Non Poor 


5.07* 
5.12 
4.89 ** 
5.10 


0.41 •* 
0.42 *• 
0.37 
0.31 


0.06** 
0.07 ** 
0.01 
0.03 


3.06** 
3.21** 
2.49 
238 


0.38 ** 
0.41 ** 
0.26 
0.31 


0.48** 
0.54** 
027 
0.40 


Race 

Black 
White 


4.67 ** 
521 


0.47 ** 
0.31 


0.03* 
0.03 


3.23 ** 
2.41 


0.37 ** 
0.32 


0.45 ** 
0.41 


Medicaid Eligible 

Yes 
No 


5.71 ** 

5.03 


0.69 •* 
028 


0.07 ** 
0.03 


4.60** 
220 


1.51** 
0.18 


0.59 ** 
0.38 


Disabled 
Yes 

No 


5.43 ** 

5.06 


0.57 ** 
0.29 


0.05 ** 
0.03 


3.94 ** 
2.26 


0.55 ** 
0.29 


0.56 ** 
0.39 


Age 

85+ Years 
Less than 85 


4.26 ** 
5.12 


0.53 '^ 
0.31 


0.17** 
0.03 


4.36** 
2.38 


2.26 ** 
0.26 


0.51** 
0.40 


Area of Residence 

Rural 
Urban 


4.72 ** 
5.25 


0.32 
0.32 


0.02 ** 
0.04 


2.08 ** 
2.57 


0.28 ** 
0.32 


0.29 ** 
0.45 


All Beneficiaries 


5.10 


0.32 


0.03 


2.43 


0.31 


0.40 



•Significantly different from comparison group a the 0.05 level. 

**Significantly different from comparison group at the 0.01 level. 

Note: Rates for each vulnerable group are contrasted with the appropriate comparison group. 

Soiffce: Part B claims and denominator file for a sample of Medicare beneficiaries, 1991. 
Prepared by: Center for Health Economics Research 



37 



Table 7. Percent of persons with a physician visit and mean number of visits per person by health insurance 
status: selected years, 1984-1990 



Health insurance status 



Percent 
distribution 
of persons 



Percent with a 
physician visit 



Mean number of visits 
per person 



1990 1984 1986 1989 1990 



1984 1986 1989 



1990 



65 years and over^ 

Medicare only 

Medicare & other public program 

Medicare & other coverage 

18-64 years^ 

Public program 

Insured but not public program 

Uninsured 



100.0 


82 


83 


85 


86 


8.2 


9.1 


8.9 


9.2 


14.9 


76 


73 


79 


78 


7.6 


8.3 


7.5 


8.1 


7.8 


89 


86 


90 


88 


11.9 


14.0 


13.1 


14.1 


73.9 


84 


85 


87 


87 


8.3 


8.9 


8.8 


8.9 


100.0 


70 


71 


72 


73 


4.9 


5.2 


5.2 


5.4 


6.2 


84 


83 


85 


85 


10.1 


11.9 


11.1 


11.1 


76.7 


72 


73 


75 


75 


4.7 


5.0 


5.1 


5.2 


17.1 


57 


57 


57 


60 


3.7 


3.6 


3.2 


4.0 



^ Includes persons with insurance other than Medicare and unknown insurance. 
^Includes persons with unknown insurance. 

Source: National Health Interview Survey, National Center for Health Statistics. 
Prepared by: Office of Research and Demonstrations. HCFA 



38 



Table 8. Utilization, access, and satisfaction indicators, by age: 1991-1992 



Type of Regular Source 

Physician's office 

Other place with regular physician 

Other place with no reguJar physician 

None 





1991 






1992 




All 




Elderly 


All 




Elderly 


Medicare 


Disabled 


(Age 65 


Medicare 


Disabled 


(Age 65 


Beneficiaries 


(Under Age 65) 


and Over) 


Beneficiaries 


(Under Age 65) 


and over) 


67.0% 


573%* 


68.0% 


69.4% 


58.4%* 


70.4% 


n 19.7% 


24.6%* 


19.2% 


16.9% 


20.0% 


16.6% 


ician 4.5% 


9.1% 


4.0% 


4.1% 


9.2%* 


3.6% 


8.8% 


9.0% 


8.8% 


9.7% 


12.4% 


9.4% 



Physician Use 

Percent with: 

Physician visit (any setting) 86.5% 

Physician visit in non-hospital seeing 83.6% 

Outpatient department visit 26.7% 

Emergency room visit 17.8% 

Average number of ofTlce visits per user 

Total 6.2 

To primary care physician 4.6 

To medical specialist 3.0 

To other specialist 3.2 

To non-physician 2.1 

Hospital Use 

Percent with hospitalization 15.2% 

Percent with ACS condition 3.5% 

Preventive Use 

Percent with flu shot in previous winter 41 .0% 
Percent of women with mammogram 

in previous year 39.1% 
Percent of women with Pap test 

in previous year 49.1% 



86.1% 


86J% 


81.4% 


83.9% 


33.5%* 


26.0% 


28J%* 


16.6% 


6.3 


6.2 


4.6 


4.6 


3.5* 


3.0 


3.7* 


3.2 


2.1 


2.1 


18.4%* 


14.8% 


4.4% 


3.4% 


24.5%* 


42.7% 


30.8%* 


40.0% 


55.3%* 


48 J % 



90.4%* 
87.2% 3 
363%* 
21.8%* 



6.5* 

4.6 

3.2 

3.2 

2.1 



15.1% 
3.6% 



47.6%* 
33.6%* 
33.4%* 



893% 
82.5%* 
41.6%*' 
34.1%*' 



6.4 

4.4 
4.0* 
3.6* 
2.1 



17.4%* 
4.4% 



26.6%* 

30.1% 

41.8%*' 



90.5% 
87.7%* 
36.9% * 
213%" 



6.5 « 

4.6 
3.2 
3.2 
2.1 



15.1% 
3.6% 



49.1%' 



34.2% 



33.6%' 



Barriers to Care 

Percent reporting a health problem and 

not receiving care in jB-evious year 9.5% 22.8%* 8.1% 7.4%* 19.3%** 6.8%^ 

Of those, percent reporting a 

fmancial barrier 53.8% 69.8%* 52.2% 56.7% 71.2%* 55.8% 



Satisfaction with Care 










Percent satisfied with: 










Quality of medical care 


94.5% 


88.9%* 


95.1% 


96.1%* 


Availability of medical care 


94.2% 


88.7%* 


94.8% 


96.4%* 


Ease of getting to doctor 


92.6% 


83.5%* 


93.6% 


93.6% 


Costs of medical care 


71.0% 


61.1%* 


72.0% 


79.7%* 



92.0%* 
92.8%*' 
88.0%*' 
69.4%* ' 



96.4%* 
96.4%* 
93.9% 
80.2%* 



* Significantly different from those age 65 and over (p<0.05). 

^Significantly different over time (1991 - 1992). 

Note: Age-adjusted using the direct method of standardization. 

Sources: Medicare Current Beneficiary Survey, Round 1 and Round 4 Data; Medicare NCH Claims for MCBS Population. 
Prepared by: Center for Health Economics Research. 



39 



Table 9: Influenza immunizations per 100 persons for aged and disabled Medicare beneflciaries, 
by gender and race: 1993 

Aged beneficiaries 



Gender 










and race 


AUAges 


65-74 yrs. 


75-84 yrs. 


85+ yrs 


All Persons 


25.1 


23.9 


27.0 


25.3 


Men 


25.1 


23.0 


28.3 


30.1 


Women 


25.1 


24.6 


26.2 


23.6 


White 


27.3 


26.3 


29.0 


26.7 


Black 


11.2 


10.4 


12.3 


12.5 



Disabled beneficiaries 





All Ages 


0-44 yrs. 


45-54 yrs. 


55-64 yrs 


All Persons 


9.8 


4.8 


9.1 


15.0 


Men 


8.5 


4.1 


7.8 


13.4 


Women 


11.8 


6.0 


11.1 


17.3 


White 


11.2 


5.7 


10.2 


16.6 


Black 


4.6 


1.9 


4.5 


7.6 



Note: Immunization counts are based only on the physician component, HCPCS=Q0124. 
A complete enumeration would include the vaccine itself, HCPCS=90737. 

Source: HCFA Part B Administrative Data through December 1993. 
Prepared by: Office of Research and Demonstrations, HCFA 



40 



Table 10. Covered preventive service use for vulnerable population groups, 1991 



Mammography 



PapTest 



Pneumococcal 

Pneumonia 

Immuni2ation 



Age-sex adjusted services per 1 ,000 beneficiaries 



Shortage Areas 




All shortage combined 


240.1** 


Urban 


231.2** 


Rural 


254.9** 


Non-shcxTage 


281.3 


Poor Areas 




All poor combined 


215.3** 


Urban 


221.4** 


Rural 


191.6** 


Non-poor 


284.3 


Race 




Black 


195.0** 


White 


293.0 


Medicaid Eligible 




Yes 


156.6** 


No 


294.9 


Disabled 




Yes 


225.4** 


No 


283.1 


Age 




85+ years 


64.1** 


Less than 85 years 


287.2 


Area of Residence 




Rural 


252.0** 


Urban 


289.3 


All BeneHciaries 


278.8 



149.5** 


133.0** 


177.0 


199.7 


145.3** 


138.1** 


173.4* 


201.3 


156.7** 


205.2 


110.5** 


208.2 


166.9** 


199.3 


50.4** 


202.6 


213.1 


191.0 



197.2 



54.28** 
61.14** 
43.33 
38.05 



19.51** 
18.96** 

21.55** 
40.49 



27.46*' 
40.74 



20.91** 
40.89 



29.64** 
39.99 



23.68** 
3^.35 



34.71 
40.56 

38.91 



* Significantly different from comparison group ai the 0.05 level. 
•• Significantly different from comparison group at the 0.01 level. 
^ Age-adjusted for female enroUees only. 

Note: Rales for each vulnerable group are contrasted with the appropriate comparison group. 

Source: Part B claims and denominator file for a sample of Medicare beneficiaries, 1991. 
Prepared by: Center for Health Economics Research. 



41 



Table 11. Ambulatory Care Sensitive (ACS) admission rates for vulnerable population groups, 1991 



Bacterial 
Pneumonia 



Shortage Area 

All shortage combined 11.1* 

Urban 10.3 

Rural 12.3** 

Non shortage 10.4 



Asthma 



Congestive 
Heart 
Failure 



Diabetes w/ 
Complications* 



(age-sex adjusted admissions per 1,(X)0 beneficiaries) 



Total 



3.8** 


19.1** 


4.0** 


71.8** 


4.7** 


21.5** 


4.7** 


77.7** 


2.4 


15.3 


3.0 


62.5 


2.7 


15.7 


2.8 


60.8 



Poverty Area 










All Poor combined 

Urban 

Rural 
Non Poor 


11.6** 
10.5 
15.6** 
10.3 


4.1** 
4.2** 
3.7** 
2.7 


21.2** 
21.7** 
19.6** 
15.5 


4.8** 
4.9** 
4.6** 

2.7 


Race 

Black 
White 


9.7** 
10.6 


4.6** 
2.6 


25.3** 
15.2 


6.8** 

2.5 


Medicaid Eligible 

Yes 
No 


23.4** 
9.0 


6.0** 
2.4 


32.6** 
14.1 


6.5** 
2.4 


Disabled 

Yes 

No 


16.4** 
9.8 


5.9** 
2.4 


27.2** 
14.6 


6.1** 

2.2 


Age 

85+ years 

Less than 85 years 


30.0** 
9.9 


2.4** 
2.8 


39.2** 
15.3 


2.3** 
2.9 


Area of Residence 

Rural 
Urban 


13.0** 
9.4 


2.8 

2.7 


15.7 
16.0 


3.0 
2.8 



All Beneficiaries 



10.4 



2.7 



15.9 



2.9 



61.4 



* Significantly different from comparison group at 0.05 level. 

** Significantly different from comparison group at 0.01 level. 

^ Includes ketoacidosis, coma, and all other complications. 

'' Includes all ACS conditions, not just those shown here. 

Note: Some national rates for specific Ambulatory Care Sensitive conditions may vary from those obtained from 100 percent data due h 
sampling. 

Source: Pan A claims and denominator file for a sample of Medicare beneficiaries, 1991. 
Prepared by: Center for Health Economics Research 



42 



Table 12. Comparison of age-adjusted rates of selected procedures in elderly black and white Medicare beneficiaries, 
and 30-day post-admission death rates. 1990 and 1992 



Procedure rale 



1220. 



Number 



Rate/* 
LQQQ 



Black/ 

white 

ratio 



Number 



1992 Change 

Black/ in rate, 

Rate/* white 1990-92 

1.000 ratio (percent') 



30-dav post-admission death rate 



i22Q. 



Rate/** 
LQQO 



Black/ 

white 

ratio 



2221 



Rate/** 
LQOQ 



_ Change 
Black/ in rate, 
white 1990-92 
ratio (percent) 



Heart and Vascular Procedures 

Cardiac catheterization 

White 334,039 13.82 0.65 409.074 16.19 

Black 18,689 8.97 23,539 11.05 

Percutaneous transluminal coronary angioplasty (PTCA) 

White 88,594 3.56 0.40 

Black 2,942 1.41 

Coronary artery bypass graft (CABG) 

White 90,749 3.64 0.37 

Black 2,792 1.34 

Carotid endanerectomy 

White 43,314 1.73 0.30 

Black 1,090 0.52 

Orthopedic and Back Procedures 
Reduction of fracture of femur 

0.42 



0.47 



White 121,773 


4.76 


Black 4,343 


2.02 


Other arthroplasty of 


hip 


White 62,945 


2.46 


Black 2,474 


1.15 


Total knee replacement 


White 80,990 


3.24 


Black 4,256 


2.02 


Total hip replacement 


White 63,260 


2.52 


Black 2,408 


1.14 


Laminectomy 




White 33,852 


1.36 


Black 1,536 


0.74 


Excision of disk 




White 30,589 


1.23 


Black 1,289 


1.62 


Spinal fusion 




White 11,387 


0.46 


Black 581 


0.28 



0.62 



0.45 



0.54 



0.50 



0.61 



125,610 


4.98 


4,703 


2.21 


121.020 


4.79 


3,920 


1.85 


60,090 


2.36 


1,569 


0.73 


132,447 


4.99 


4,950 


2.21 


71.178 


2.69 


2,715 


1.21 


105,670 


4.17 


5.805 


2.68 


67.876 


2.66 


2,806 


1.30 


36,069 


1.54 


1.737 


0.81 


33,816 


1.35 


1,451 


0.68 


16,092 


0.64 


846 


0.40 



0.68 



0.44 



0.39 



0.31 



0.44 



0.45 



0.64 



0.49 



0.53 



0.50 



0.63 



17.2 
23.2 

39.9 
56.7 

31.6 
38.1 

36.4 
40.4 



4.8 
9.4 

9.4 
5.2 

28.7 
32.7 

5.6 
14.0 

13.2 
9.5 

9.8 
9.7 

39.1 
42.9 



+ na 

+ na 

+ 23.88 

+ 27J9 

+ 32.87 

-I- 42.11 

+ 18.54 

+ 23.66 



58.28 
45.71 

55.88 
53.35 

5.52 
8.75 

14.71 
15.42 

11.75 
18.53 

6.38 
15.48 

18.87 
20.99 



na 
na 



na 
na 



1.16 23.27 
24.38 

1.28 40.57 
45.61 

1.28 15.53 
20.43 



0.78 57 J 1 
47.71 

0.95 55.27 
46.68 



1.59 



1.05 



1.58 



2.43 



1.11 



4.28 
6.31 

13.56 
14.98 

10.07 
20.38 

5.37 
11.41 

13.80 
21.57 



na 
na 

1.05 



1.12 



1.32 



0.83 



0.84 



1.47 



1.10 



2.02 



2.12 



1.56 



na 
na 

-2.6 
-11.6 

23.4 + 
8.3 

-16.2 + 
-13.7 



-1.3 
4.4 

-1.1 

-12.5 

-22.5 + 
-27.9 

-7.8 
-2.9 

-14.3 + 
10.0 

-15.8 
-26.3 

-26.9 + 
2.8 



43 



Table 12 (codL). Comparison of age>ad justed rates of selected procedures in elderly black and white Medicare beneficiaries, 
and 30-day post-admission death rates, 1990 and 1992 









Procedure rate 






- 


30-day post-admi 
1990 


ssion death rate 

1992 

Black/ 






1990 






1992 




Change 
m rate. 


Change 






Black/ 






Black/ 




Black/ 


in rate. 




Rate/* 


white 




Rate/* 


white 


1990-92 


Rate/** 


white 


Rate/** 


white 


1990-92 


NumJ?er 


l.OOO 


raiifi 


Nunil?er 


1.000 


raiip 


fpercen 


tl 


1.000 


ratio 


1.000 


ratiQ 


(perpent) 


Other Procedures 


























Prostatectomy 
While 226.416 


22.41 


0.91 


211,851 


20J5 


0.97 


-8.3 


+ 


9.59 


1.18 


9.22 


1.27 


-3.9 


Black 16.911 


20.44 




16,738 


19.99 




-2.2 


+ 


11.31 




11.72 




3.6 


Cholecystectomy 
White 131.430 


5.25 


0.62 


74338 


2.90 


0.75 


-44.8 


+ 


29.87 


1.33 


41.01 


1.03 


37.3 + 


Black 6,919 


3.28 




4,706 


2.17 




-33.8 


+ 


39.77 




42.40 




6.6 


Repair of inguinal hernia 
White 59,174 2.34 


0.72 


41,937 


1.62 


0.85 


-30.8 


+ 


13.75 


1.53 


16.68 


1.13 


21.3 + 


Black 3.489 


1.68 




2,936 


1.38 




-17.9 


+ 


21.10 




18.81 




-10.9 


Mastectomy 
White 54.284 


3.61 


0.75 


51,953 


3.43 


0.81 


-5.0 


+ 


5.22 


1.54 


4.96 


1.50 


-5.0 


Black 3.491 


2.72 




3,641 


2.77 




1.8 




8.03 




7.42 




-7.6 


Hysterectomy 
White 51,258 


3.46 


0.63 


54,906 


3.67 


0.60 


6.1 


+ 


7.40 


2.22 


7.44 


2.04 


0.5 + 


Black 2,779 


2.19 




2,897 


2.21 




0.9 




16.41 




15.16 




-7.6 


Appendectomy 
White 11,157 


0.45 


0.73 


11,522 


0.45 


0.76 


0.0 




27.39 


1.75 


27.64 


2.33 


0.9 


Black 691 


0.33 




729 


0.34 




3.0 




47.84 




64.44 




34.7 


Incidental Appendectomy 
White 10.635 0.43 


0.84 


9,448 


0.37 


0.84 


-14.0 


+ 


30.74 


1.46 


34.01 


1.33 


10.6 


Black 747 


0.36 




670 


0.31 




-13.9 


+ 


44.77 




45.16 




0.9 



* per 1.000 enroUees 
*• per 1,000 discharges 
na Not applicable because cardiac catherization is a diagnostic procedure that is often followed by a surgical procedure 

+ significant at p value < 0.01 

SOURCE: Data from the Health Care Financing Administralion, Bureau of Data Management and Strategy, Medicare Provider Analysis and 

Review files. 
Prepared by: Office of Research and Demonstrations. HCFA 



44 



Table 13. Mean caseload per physician, by specialty group: 1991-1992 





Expected 


Number 












National 


of 


1991 


1992 


Change in 






Mean Price 


Sample 


Mean 


Mean 


Mean 


Percent 


Specialty* 


Change(%)'' 


Physicians 


Caseload 


Caseload 


Caseload 


Change 


Primary Care 


n/a 


1^78 


277 


289 


12 ** 


4 


Family Practice 


15 


916 


277 


287 


10 ** 


4 


General Practice 


17 


657 


275 


289 


14 * 


5 



Psychiatry 



306 



64 



69 



Medical Specialties 


n/a 


1,604 


374 


396 


22 ** 


6 


Allergy/Imm unology 


n/a 


36 


92 


102 


10 


11 


Physical Medicine 


n/a 


32 


185 


195 


10 


6 


Pediatrics 


n/a 


71 


39 


41 


2 


6 


Gastroenterology 


-10 


93 


421 


458 


37 ** 


9 


Cardiology 


-9 


210 


577 


653 


76 ** 


13 


Nephrology 


-6 


43 


328 


355 


28 ** 


8 


Neurology 


-4 


101 


365 


363 


-2 





Pulmonary Disease 


-3 


62 


437 


462 


25 * 


6 


Internal Medicine 





915 


371 


384 


13 ** 


4 


RAP*= 


n/a 


798 


774 


836 


62 ** 


8 


Anesthesiology 


-11 


354 


204 


226 


22 ** 


11 


Pathology 


-10 


103 


781 


796 


15 


2 


Radiology 


-10 


338 


1373 


1,492 


119 ** 


9 


Surgery 


n/a 


1,994 


291 


305 


13 ** 


5 


Obstetrics/Gynecology 


n/a 


417 


66 


70 


4 ** 


7 


Oral Surgery (Dentist) 


n/a 


65 


17 


18 


2 


11 


Thoracic Surgery 


-14 


69 


235 


244 


9 


4 


Ophthalmology 


-11 


214 


795 


835 


40 * 


5 


Neurosurgery 


-10 


69 


155 


163 


7 


5 


General Surgery 


-8 


373 


239 


241 


2 


1 


Orthopedic Surgery 


-8 


324 


235 


246 


12 ** 


5 


Plastic Surgery 


-8 


63 


124 


129 


5 


4 


Urology 


-6 


130 


494 


545 


51 ** 


10 


Dermatology 


-1 


116 


643 


663 


20 


3 


Otolaryri^ology 


2 


141 


293 


303 


10 


4 


LLP 


n/a 


1,030 


118 


123 


6 ** 


5 


Podiatry Surgery 


6 


113 


396 


403 


7 


2 


Chiropractic 


12 


529 


45 


47 


2 ** 


5 


Optometry 


20 


388 


135 


146 


11 ** 


8 



Data for ihe six broad specialty groups may include physicians in detailed specialties not shown. 

Percent change in average price per service forecasted by HCFA in Federal Register 56(227). Nov. 25, 1991. 

Subtotal for radiology, paihology. and anesthesiology. 
*• = statistically significant at .01 level 
* = statistically significant at .05 level 
n/a = not available 

Note: Data derived from upper-bound estimation method; see text for definition. 

LLP = Limited License Practitioners; Oral Surgeons (Dentists) are also LLP but included with Surgeons for this analysis. 



Source: HCFA Part B Monitoring System: National Claims History Physician Sample File. 
Prepared by: Office of Research and Demonstrations, HCFA 

45 



Table 14. Mean allowed charges per physician, by specialty group: 1991-1992 





Expected 


Number 


1991 


1992 








National 


of 


Mean 


Mean 


Change in 






Mean Price 


Sample 


Allowed 


Allowed 


Mean Allowed 


Percent 


Specialty* 


Change i%)^ 


Physicians 


Charges 


Charges 


Charges 


Change 


Primary Care 


n/a 


1^79 


$37,362 


541,039 


$3,677 •• 


10 


Family Practice 


15 


916 


40,235 


44,217 


3,982 •* 


10 


General Practice 


17 


658 


33,364 


36,603 


3,239 •* 


10 


Psychiatry 


-2 


306 


19,753 


21.764 


2,011 


10 


Medical Specialties 


n/a 


1,610 


111,686 


114,041 


2356 


2 


Allergy/Immunology 


n/a 


36 


18,391 


23,820 


5.428 *• 


30 


Physical Medicine 


n/a 


32 


52396 


56,049 


3,653 


7 


Pediatrics 


n/a 


73 


6,519 


7,690 


1,171 * 


18 


Gastroenterology 


-10 


93 


157,680 


152,084 


-5,596 


-4 


Cardiology 


-9 


212 


217,537 


221,450 


3,913 


2 


Nephrology 


-6 


43 


192,054 


193,290 


U36 


1 


Neurology 


-4 


101 


71,001 


64,377 


-6,625 


-9 


Pulmonary Disease 


-3 


62 


135,552 


133,313 


-2339 


-2 


Internal Medicine 





917 


98,587 


102,241 


3,654 • 


4 


RAP^ 


n/a 


798 


76,901 


78,446 


1,546 


2 


Anesthesiology 


-11 


354 


49,632 


49,006 


-626 


-1 


Pathology 


-10 


103 


60,085 


63J97 


3312 


6 


Radiology 


-10 


338 


111,005 


1 14,385 


3379 


3 


Surgery 


n/a 


1,994 


97.020 


94,082 


-2,938 ** 


-3 


Obstetrics/G ynecolog> 


' n/a 


417 


9,879 


9,714 


-165 


-2 


Oral SiTgery (Dentist) 


n/a 


65 


3,238 


2,802 


-436 


-13 


Thoracic Surgery 


-14 


69 


232,038 


226,249 


-5,789 


-2 


Ophthalmology 


-11 


214 


266,963 


263,707 


-3356 


-1 


Neurosurgery 


-10 


69 


88,531 


83,144 


-5387 


-6 


General Surgery 


-8 


373 


92,426 


82,454 


-9,972 ** 


-11 


Orthopedic Surgery 


-8 


324 


95,978 


93,256 


-2,722 


-3 


Plastic Surgery 


-8 


63 


53,050 


49,472 


-3,578 


-7 


Urology 


-6 


130 


168,929 


175,410 


6,480 


4 


Dermatology 


-1 


116 


104,593 


103,204 


-1,389 


-1 


Otolaryngology 


2 


141 


45,048 


44,081 


-967 


-2 


LLP 


n/a 


1,030 


11,992 


12,616 


625 •* 


5 


Podiatry Surgery 


6 


113 


52,214 


49,131 


-3,083 * 


-6 


Chiropractic 


12 


529 


5,710 


6,600 


890 ** 


16 


Optometry 


20 


388 


8,842 


10,185 


1,343 ** 


15 



NOTE: LLP = Limited License Pracutioners: Oral Surgeons (Dentists) are also LLP but included with Surgeons for this analysis 

^ Data for the six broad specialty groups may include physicians in detailed specialties not shown. 

''Percent change in average price per service forecasted by HCFA in Federal Register 56(227), Nov. 25, 1991. 

^ Subtotal for radiology, pathology, and anesthesiology. 

•* = statistically significant at .01 level 

* = statistically significant at .05 level 

n/a = not available 

Source: HCFA Part B Monitoring System: .National Claims History Physician Samcle File. 

Prepared by: Office of Research and Demonstrations. HCFA. 



46 



Table 15. Primary care and medical specialties per 100,000 Medicare beneficiaries, by region, II.S. 1984-1992 













Year 










Average annual 






















percent change 




1984 


1985 


1986 


1987 


1988 


1989 


1990 


1991 


1992 


1984-91 1991-92 






Primary 


care and medical specialties per 100,000 Medicare beneficiaries 






U.S. Total 


839 


848 


856 


873 


899 


914 


918 


934 


950 


1.55 


1.71 


Region 
























Northeast 


954 


967 


982 


1,017 


1,057 


1,082 


1.092 


1,124 


1,154 


2.38 


2.67 


Midwest 


751 


757 


764 


773 


793 


805 


804 


821 


836 


1.28 


1.83 


South 


719 


731 


743 


763 


785 


795 


799 


811 


824 


1.74 


1.60 


West 


1.048 


1,052 


1,045 


1,044 


1,069 


1,087 


1.091 


1,096 


1,105 


0.65 


0.82 


Metropolitan Areas 


1,010 


1,020 


1,030 


1,054 


1,086 


1.105 


1,110 


1,133 


1,156 


1.66 


2.03 


Large Mecro. Core 


1,251 


1,265 


1,278 


1,313 


1,358 


1,382 


1,392 


1,429 


1,468 


1.92 


2.73 


Large Metro. Fringe 


937 


950 


964 


990 


1,025 


1,052 


1,058 


1,078 


1,098 


2.03 


1.86 


Medium Metropolitan 


856 


864 


873 


891 


917 


931 


938 


953 


969 


1.55 


1.68 


I ^,sser Metropolitan 


779 


786 


791 


797 


813 


829 


830 


842 


856 


1.12 


1.66 


Nonmetropolitan Areas 


385 


391 


394 


392 


400 


405 


402 


399 


397 


0.52 


-0.50 


Urbanized Adjacent 


452 


457 


461 


453 


464 


469 


466 


463 


461 


0.35 


-0.43 


Urbanized Nonadjaceni 


625 


634 


637 


637 


652 


661 


661 


665 


668 


0.89 


0.45 


Less Urban Adjacent 


322 


327 


331 


330 


335 


339 


334 


329 


323 


0.32 


-1.82 


T ^.ss Urban Nonadjacent 


. 357 


361 


362 


359 


366 


369 


366 


363 


361 


0.24 


-0.55 


Thinly Pop. Adjacent 


226 


228 


231 


232 


238 


237 


229 


226 


224 


0.02 


-0.88 


Thinly Pop. Nonadjacent 222 


228 


233 


231 


237 


235 


231 


224 


218 


0.15 


-2.68 


Ex Ante Impact Group 
























Increase 


800 


806 


804 


816 


834 


849 


854 


865 


875 


1.13 


1.16 


No Change 


740 


752 


763 


783 


808 


826 


834 


850 


865 


2.00 


1.76 


Moderate Decrease 


856 


866 


876 


896 


925 


939 


942 


966 


989 


1.75 


2.38 


Large Decrease 


924 


932 


939 


949 


974 


989 


990 


998 


1,009 


1.11 


1.10 



Note: Ex Ante Impact Group refers to areas grouped according to expected changes in Medicare physician payment 
under PPR, as published in the Federal Register Vol. 56 (227). See Appendix II. Technical Note C. 

Sotirce: Derived from tables prepared by Project HOPE: based on the Area Resource File and HCFA Denominator File. 
Prepared by: Office of Research and Demonscraiions. HCFA 



47 



Appendix I 

Impacts of the Medicare Fee Schedule on 
Physicians/Suppliers and Procedures 



Prepared by: William J. Sobaski 

Office of Research and Demonstrations 

Health Care Financing Administration 

April 1994 

Revised May 31, 1994 



Appendix I 

Impacts of the Medicare Fee Schedule on 
Physicians/Suppliers and Procedures 



mTRODUCTION 

This appendix presents overviews of some major impacts of the Medicare Fee Schedule 
(MFS) during 1992, its first transition year. Similarly, impacts seen thus far in 
preliminary 1993 claims data are discussed. 

What Were the Expected Impacts? 

When the MFS was enacted, it was generally known that beginning in 1992: 1) There 
would be numerous changes in the amount Medicare allowed for particular services in 
most places; 2) New codes and definitions would be introduced for most kinds of non- 
surgical visits; 3) Many formerly locally determined definitions and payment policies 
such as global periods for surgery would become nationally uniform and, by statute, 
separate payments would no longer be made for interpretation of standard 
electrocardiograms performed or ordered as part of or in conjunction with a visit or a 
consultation; 4) A new and expanded set of Health Care Financing Administration 
(HCFA) physician specialty codes would be introduced; and 5) Physicians would be 
facing some new incentives such as the Medicare Volume Performance Standards and 
more stringent limits on "extra-billing." It has also been long known that Medicare 
utilization and payments have varied between population subgroups and across regions 
and States. In designing the MFS and the accompanying payment policies, there was 
impetus to narrow the range in payments across regions and States, between specialists 
and generalists, and between urban and rural areas. For instance, the legislative 
specifications for calculating the Geographic Practice Cost Index for the work 
component of the relative value scale used in the MFS allowed for recognition of only 
one-fourth of the actual difference between each locality and the national average 
measure for physician work. Also, several States that had separate rural and urban 
Medicare physician payment localities in 1991 changed to statewide payment localities 
in 1992 or 1993. 

Some concerns about access to care that were widely felt included: 1) That too many 
procedures were being performed while too little primary care was obtained; 2) That 
there was an over-supply of specialized physicians compared to primary care physicians 
due in large measure to disparities in payments and earnings; and 3) While the total 
supplies of physicians and of nonphysician caregivers were growing faster than the 
population, there were large geographic imbalances in their distribution. 



Appendix I-l 



Any or all of the changes in factors such as these could alter the year-to-year measures 
of utilization and access used in this appendix, as could changes in medical technology 
or changes in the needs and preferences of patients. 

This appendix examines some of the impacts of the MFS. It focuses on changes 
between 1991 and 1992 in patterns of Medicare allowed charges (1) for broad types of 
medical services, (2) among various categories of physician and suppher specialties, (3) 
between States,and (4) among sites of service. Last year's report provided information 
on changes from 1991 to 1992 using prehminary 1992 distributions of allowed charges 
for Part B "fee for service" claims by type of service, State and physician/supplier 
category. 

METHODS 

All data on Medicare allowed charges come from the HCFA National Claims 
History/Physician/Supplier Procedure Summary file (NCH/PSP). Complete data for 
1991 and 1992 were used, as were all available data for services provided in 1993 as 
reported through the end of December 1993 (1993 data represent about 85 percent of 
the expected full year data). Most of these data were compiled by using HCFA's Part 
B extract system (BESS), but the HCFA Office of Statistics and Data Management 
tabulated the preliminary data for 1992 (i.e., reported through the end of December) 
used in Table 1-5. Enrollment data used in Tables 1 and 4 are the counts supplied by 
the Office of Research, Division of Program Studies from the Medicare enrollment files 
as of June 30 for 1991 and 1992. The term "physician services" as used in this report 
refers to services billed by physicians or osteopaths or dentists, whether or not the 
service was paid by the Medicare fee schedule. 

The aggregations used in this report for types of medical services and for categories of 
physician specialties are somewhat broader than those used in last year's report. Details 
of the changes in aggregations are provided in the text on results. 

RESULTS 

Impacts Among Type of Service Categories 

The final data on 1992 Part B "fee for service" claims processed by Medicare carriers, 
which include both MFS and non-MFS services, showed little change in allowed charge 
patterns from those indicated by the preliminary 1992 data. There were clearly 
increases in the proportions of allowed charges for medical and consultation services, 
and also for diagnostic laboratory tests, radiation therapy and other (primarily 
nonphysician) types of Part B Benefits. The proportions of allowed charges for surgery, 
anesthesia, assistants at surgery and for diagnostic X-rays fell. 



Appendix 1-2 



Table I-l presents a summary of calendar 1991 and 1992 allowed charges data for four 
major groupings of physician services. One group combines medical and consultation 
services (often caUed "evaluation and management services"). A second group includes 
surgery, anesthesia, assistants at surgery and radiation therapy (often called "procedural 
medicine"). A third group is diagnostic X-ray and diagnostic laboratory tests. The 
remaining grouping includes "all other" services covered by Medicare Part B (most of 
which are not physician services). 

As shown in Table I-l, total amounts allowed by Medicare carriers increased from $42.9 
billion in 1991 to $43.9 billion in 1992 or by over one billion dollars (2.4 percent). The 
amounts allowed for medical and consultation services grew by more than $1 billion, a 
7.5 percent increase. The decline for surgery and "procedural" services was $815 
million, a 5.8 percent overall decrease. There was a small overall increase in amounts 
allowed for diagnostic X-rays and lab tests (primarily for lab tests). The percent 
increase was for all other (mainly nonphysician) services, which grew by almost three- 
quarters of a biUion dollars, or 12 percent. 

Part of these changes was due to nationwide increase in the number of beneficiaries 
between 1991 and 1992. The Part B enrollment increase for the fee-for-service sector 
(total Part B enrollment minus health maintenance organization (HMO) enrollment) 
was nearly 1.7 percent. Adjustment for the growing enrollment lowers the 2.4 percent 
gross total growth to 0.7 percent per enrollee, and similarly reduces the growth for each 
grouping. 

Changes from 1991 to 1992 in allowed dollar amounts provide some indication that the 
MPS stimulated the kinds of changes that were intended and expected among service 
categories mainly provided by physicians. However, to draw any inferences about 
changes in utilization or access, it is important to consider the results from the 
perspective of the services provided to beneficiaries, in addition to the perspective 
provided here of physician services billed. 

Preliminary 1993 Patterns. For 1993 physician billed services reported to HCFA 
through December 31, 1993, there continued to be increases in the share of Part B 
allowed charges for medical and consultations services (from 42.4 percent in 1992 to 
44.7 percent in preliminary 1993), declines for the surgery and procedures category 
(from 37.2 percent in 1992 to 35.2 percent in preliminary 1993), and little change for 
diagnosfic tests (from 18.4 percent to 18.1 percent). These preliminary 1993 data 
suggest that the changes intended by the fee schedule legislation continued. 

Impacts Among Physician/Supplier Specialty Categories 

Table 1-2 provides more insight into the changes that occurred by showing allowed 
amounts for various categories of physicians and suppliers by specialty category. 



Appendix 1-3 



The specialty categories used in this report are somewhat broader than those used for 
the 1993 report. Major changes were the combining of the mental health specialties 
with medical specialties and the reclassification of dental and osteopathic specialties into 
the medical specialty, surgical specialty or other medical doctor (MD) specialty 
categories. 

If only the allowed charges for services (MFS and non-MFS services combined) billed 
by physicians (as defined by Medicare law ~ includes some limited license practitioners) 
are considered, total allowed charges decreased slightly from $34.9 bilhon in 1991 to 
$34.9 billion in 1992, i.e., about 0.1 percent. A similar adjustment for the growth in the 
Medicare Part B fee for service enrollment as discussed earlier results in a negative 
growth rate of about -1.8 percent. This slight decline in the annual per enrollee amount 
of allowed charges for physician services was probably the first in Medicare's history. 

The analysis of changes by specialty is complicated by several factors including the 
changes that were going on in classification codes for specialties; the implementation of 
the Unique Physician Identification Number (UPIN); and changes in the supply of 
various types of physician specialties that occurred in 1991 and 1992. 

Changes in Physicians by Specialty 

In early 1992, Medicare carriers were encouraged to implement an expanded system of 
specialty designation codes. HK Research performed an analysis of changes in specialty 
designations between the September 1991 UPIN and carrier reports on specialty 
changes in early 1992 (HK, 1993). The analysis included 597,755 physicians of whom 
27,196 (or 4.5 percent) changed or redesignated their specialty category. 

The specialties that had the absolute largest changes included internal medicine (8,280 
left the category while 1,594 entered); general practice (GP) (5,784 left while 1,357 
entered); miscellaneous (1,783 left while 14 entered); multispecialty group (1,822 left 
while 305 entered); family practice (FP) (1,629 left while 2,920 entered); and general 
surgery (1,378 left while 552 entered). Hence, each of these categories except Family 
Practice had a sizable net decline. 

Categories having numerous entrants included-.emergency medicine (4,136 entrants 
including 2,381 former GPs; 727 former FPs; 515 former internists; 227 former 
miscellaneous, and 287 others from 33 other categories); family practice (2,920 entrants, 
including 2,089 former GPs; 282 former multi-specialty group, 212 former internists and 
327 others from 36 other categories); hematology/oncology (1,534 entrants including 
1,391 former internists and 143 from 24 other categories); internal medicine (1,516 
entrants including 398 former GPs, 295 former multi-specialty groups; 257 former 
cardiologists, 144 former gastroenterologists, 105 former pulmonary disease, and 317 
from 37 other categories); general practice (1,357 entrants including 519 former FPs, 
235 former General Surgeons, 192 former Internists and 411 from 36 other categories); 



Appendix 1-4 



oral surgery (1,391 entrants including 1,361 former miscellaneous); and rheumatology 
(1,002 entrants, including 929 former internists). 

Former Internists also predominate the new categories for endocrinology (861 of 957 
entrants), infectious disease (546 of 605), medical oncology (437 of 470), critical care 
intensivists (151 of 270), geriatrics (178 of 270 ), as well as to the larger subspecialties 
like cardiology (798 of 980), gastroenterology (570 of 643), pulmonary disease (510 of 
585) and nephrology (354 of 403). 

There were 754 attritions from diagnostic radiology, mainly 512 to radiation oncology 
and 82 to invasive radiology. Thoracic surgery had 569 attrition, mainly 285 to cardiac 
surgery and 126 to vascular surgery and 89 to general surgery. As a result, over 80 
percent of both the new invasive radiology and radiation oncology categories came from 
diagnostic radiology, about 70 percent of the new cardiac surgery category came from 
thoracic surgery and about 60 percent of the new vascular surgery category came from 
general surgery. 

We must emphasize that these changes in specialty designations had no impact on 
Medicare payments for services provided by physicians or suppliers. The main purpose 
of the initiative was to enable the development of more meaningful data and statistics 
for utilization review and analysis. 

Nonetheless, the broad overview presented in Table 1-2 provides some of the flavor of 
what happened among physicians after the MFS was implemented. The primary care 
category and the medical specialties category each had increases in allowed charges of 
over $400 million. Allowed amounts for the chiropractor - optometrist - podiatrist 
category rose by over $40 milhon, and those for other MD specialties (anesthesiology, 
pathology, radiology) rose by almost $20 milhon. The largest dechne was in the category 
"chnics and unknown" which fell by $436 milhon. This category was highly impacted by 
the specialty re-designation effort. The dechne for surgical specialties was nearly $500 
million. 

Preliminary 1993 Patterns. The pattern of allowed charges by specialty category in the 
preliminary 1993 data in Table 1-3 shows continued growth in the percent of allowed 
charges for physician services for both primary care (from 9.7 percent in 1992 to 
10.4 percent in preliminary 1993) and medical specialties (from 36.2 percent in 1992 to 
37.4 percent in preliminary 1993). The proportion for surgical specialties was not 
changed greatly (33.0 percent in 1992 versus 32.6 percent in preliminary 1993). 
Decreases occurred in the other physician specialty category (from 14.2 percent in 1992 
to 13.4 percent in preliminary 1993) and in the category clinic/unknown (from 3.6 
percent in 1992 to 2.8 percent in preliminary 1993). 



Appendix 1-5 



In future reports, from 1993 onward, it will be possible to present year-to-year changes 
in activity for each HCFA physician or supplier specialty code. However, to report on 
changes for earher periods, it will be necessary to continue to use broader categories. 

Geographic Impacts 

Last year's report showed the changes in Medicare allowed charges by State between 
the full year of 1991 and preliminary incomplete data for 1992. The basis for the 
calculations were the HCFA type of service categories 1 through 8, mainly physician 
categories. The changes were illustrated by using an index which some readers found 
difficult to interpret. 

Table 1-4 presents the percent changes from 1991 to 1992 in Part B fee-for-service 
enrollment and in allowed charges for services billed with physician specialty codes by 
State. In 25 States and the District of Columbia, allowed amounts for physician 
specialty bills increased more rapidly than enrollment in the Medicare Part B fee-for- 
service sector. In California and Arizona, fee-for-service enrollment and allowed 
charges both fell. In the other 23 States and Puerto Rico, fee-for-service allowed 
charges increases were less than those for enrollment. 

The first pair of columns in Table 1-5 shows allowed charges for all physician specialty 
coded services for calendar years 1991 and 1992. National amounts are shown for 
railroad retiree claims, and State amounts are presented for claims for services to other 
enroUees. The second pair of columns in this table present the allowed amounts as 
reported through December 31,1992 and 1993. The latter provide some indication of 
the impact for the 1993 MPS. 

First Year Impact 

The transition formula for phasing in the implementation of the MPS was designed to 
provide the largest changes in the first year relative to historic payments. Table 1-5 
shows that national total allowed charges for physician specialty services in the fee-for- 
service sector of Medicare Part B were virtually equal in 1991 and 1992. As was noted 
earlier, there was a slight decline in the average per enroUee amount of physician fee- 
for-service allowed charges (probably the first in Medicare's history). 

In these final 1992 tallies, Medicare allowed charges fell in 16 States and for the 
railroad retirement board (RRB), were virtually unchanged in 2 States and had some 
increase in 32 States, the District of Columbia and Puerto Rico. The pattern of 
winners and losers was fairly similar to that suggested last year. But Puerto Rico and 4 
States —Maryland, Illinois, New York and Ohio -that seemed to be losing in the 
preliminary 1992 data for the physician service types wound up gaining. Conversely, 
Kansas and Oklahoma had declines, although they seemed gainers in the preliminary 
data. Also, Virginia and Rhode Island, which the preliminary data suggested as gainers, 



Appendix 1-6 



wound up with virtually no change. These changes in geographic impact results suggest 
that caution must be exercised when considering the detailed findings with preliminary 
data, 

California had the largest decline ~ about 6.4 percent. About 1 percent of this decline 
might be explained from the fact that California experienced an absolute decrease in 
the fee-for-service Medicare Part B enrollment of over 23,000 persons or about 
1 percent of the 1991 enrollment. Other States with declines in fee-for-service allowed 
charges for services by physician specialties included Alaska (-4.8 percent), Nevada 
(-4.2), Arkansas, Louisiana and New Mexico (each -3.2 percent), Connecticut 
(-2.8 percent), Arizona (-2.4 percent), Hawaii (-2.3 percent), Florida (-1.8 percent), 
Nebraska (-1.6 percent), Oklahoma (-1.4 percent), Kansas (-1.0 percent), Texas and 
West Virginia (each -0.9 percent), and Washington (-0.6 percent). There was slight 
shrinkage from 1991 to 1992 in the fee-for-service Part B Medicare enrollment in 
Arizona and in Rhode Island. 

Preliminary 1993 impacts. To provide an indication of the second year impact in the 
transition to the MPS, Table 1-5 shows the preliminary allowed charges for RRB and 
States recorded as of December 31 for 1992 and 1993. As has been noted previously, 
the ultimate cailendar year figures are calculated from claims received as of June 30 of 
the following calendar year. 

In these preliminary data, Arizona and Washington are the only States which 
experienced declines in 1992, that are also showing declines (-1.3 percent and -3.2 
percent respectively) thus far in 1993. These declines might be a reflection of 
shrinkage of the fee-for-service sector in those States. Oregon appears to be declining 
(-2.8 percent) in preliminary 1993 data, after having only small (0.4 percent) growth in 
1992. 

Oregon also is a State with comparatively heavy Medicare HMO enrollment. North 
Dakota also declined (- 2.5 percent) in preliminary 1993 data, after having increased by 
about 2.3 percent in 1992. In California, Nevada, and Arkansas, the preliminary 1993 
growth rates (2.1 percent, 2.4 percent and 1.0 percent, respectively) seem to offset some 
of the 1992 declines (-6.4 percent, -4.1 percent, and -3.2 percent, respectively). The 
Texas preliminary 1993 increase (0.8 percent) roughly offsets the 0.9 percent decline for 
1992. In all other States having 1992 declines, the preliminary 1993 growth rates 
appear to be more than offsetting. They include Connecticut, Nebraska, Kansas, West 
Virginia, Florida, Lxiuisiana, Oklahoma, New Mexico, Alaska and Hawaii. 

Most of the States that had increased allowed charges in 1992 seem to be increasing at 
higher rates in preliminary 1993. The only such States indicating lower preliminary 
1993 growth than in 1992 are Utah (6.2 percent versus 6.7 percent), and Delaware 
(6.2 percent versus 8.2 percent). 



Appendix 1-7 



Again, we must note that the preliminary data may not be reliable indications of the 
full year's experience. There are differences among States in the billing and payment 
cycles for physician services, differences in enrollment changes in the fee-for-service and 
HMO sectors of Medicare Part B, differences in the size and composition of the 
supplies of physicians and other practitioners, and differences in seasonal demand 
patterns for physician services. It is also possible that by December 31, 1993, a higher 
portion of the ultimate 1993 services were reported than was the case in 1992. If so, 
the apparent growth is exaggerated. 

Impacts Among Places of Service 

Table 1-6 shows patterns of allowed charges for physician services by place where care 
was provided. Since the MFS was implemented for physician services, there has been a 
significant decline in the proportion of Part B allowed charges for services in hospital 
inpatient settings. While this trend has been noted previously as one of the impacts of 
the Medicare hospital inpatient prospective payment system (HCFA, 1991), it seems to 
have continued since 1992. There has also been somewhat of a decline in the allowed 
charges for physician services in hospital outpatient departments or emergency rooms. 
During 1992, increases occurred in office settings, ambulatory surgical centers and in 
nursing homes." In the preliminary 1993 data, the decline for allowed charges in 
hospital settings continues; the growth in allowed charges for care in office settings also 
continues. These patterns may be another indication that the MFS is achieving the aim 
to foster primary care. 

SUMMARY OVERVIEW 

The aggregate data continue to show that the MFS is largely meeting its goal of 
improving payment for primary care services and specialties while de-emphasizing 
procedural services and specialties. Similarly, by and large, there have been geographic 
impacts along the expected lines which improved payments for rural and lower income 
areas. But, as pointed out in last year's report, fewer States than anticipated 
experienced reductions, but the losses in several States, most notably California, were 
larger than expected. The proportion of payments for physician services to inpatients 
seems to have begun falling faster since the fee schedule was implemented. 

These aggregate claims data, however, do not provide very clear answers about whether 
beneficiary access to physician services or health status have changed for the better or 
for the worse. Hence, we have begun examining annual billings for an NCH sample of 
physicians to determine whether and how individual kinds of practices and their patients 
have been impacted. And, we have continued to emphasize studies of access for 
various categories of beneficiaries as are reported in other appendices of this report. 
Further research is needed to better understand the extent to which any access 
problems that may have arisen can be remedied through changes in payment levels or 
other more appropriate measures. 



Appendix 1-8 



REFERENCES 



Coulan, R.F. and G.L. Gaumer: Medicare's prospective payment system: A critical 
appraisal. Health Care Financing Review, 1991 Annual Supplement, pp. 57-58. HCFA 
Pub. No. 03322. March 1992. 

HK Research Corporation: Report on Changes in Classification of Physician Specialty. 
Cooperative Agreement No. 17-C-90159/3-02. Sevema Park, MD. July 29, 1993. 
NTIS Accession No. PB-94-152089. 



Appendix 1-9 



Table I-l. Medicare Part B fee-for-service claims: Allowed charges by type of service, 
1991 and 1992 



Total 





Surgery, 


X-ray 




Medical 


Rad. Ther., 


and 




Visits and 


Anesthesia, 


Lab 


AU 


Consultations 


and Assistants 


Tests 


Other 



Allowed charges (in millions) 



1992 


$43,942 


$14,926 


$13,301 


$8,785 


$6,930 


1991 


42,916 


13,885 


14,116 


8,727 


6,186 


Percent change 


2.4 


7.5 


-5.8 


0.7 


12.0 


Adjusted 












for Population 


0.7 


5.7 


-7.3 


-1.0 


10.2 


Increase 













SOURCES: - HCFA Part B Monitoring System: Allowed charges from HCFA National Claims History File. 
- Population information from June 30 Medicare Part B enrollment files. 



Table 1-2. Medicare Part B fee-for-service claims: Allowed charges by type of service 
and physician/supplier specialty category, 1991 and 1992 









Surgery, 


X-ray 








Medical 


Rad. Ther., 


and 








Visits and 


Anesthesia, 


Lab 


All 


Year 


Total 


Consultations 


and Assistants 


Tests 


Other 



Allowed charges (in millions) 



TOTAL 


1992 


$43,942 


$14,926 


$13,301 


$8,785 


$6,930 




1991 


42,915 


13,885 


14,116 


8,727 


6,186 


NON-PHYSICIAN 


1992 


9,088 


153 


351 


2,370 


6,214 




1991 


8,008 


230 


361 


2,051 


5,366 


Supplier 


1992 


5,668 


63 


20 


167 


5,418 




1991 


5,021 


42 


12 


193 


4,774 


Facility /Lab 


1992 


2,886 


28 


51 


2,192 


615 




1991 


2,557 


137 


103 


1,848 


469 


Practitioner 


1992 


534 


62 


280 


11 


181 




1991 


430 


51 


246 


10 


123 


PHYSICIAN 


1992 


34,854 


14,773 


12,951 


6,415 


715 




1991 


34,906 


13,655 


13,375 


6,676 


820 


Primary Care 


1992 


3,376 


2,658 


232 


459 


27 


Specialties 


1991 


2,976 


2,237 


227 


479 


33 


Medical Specialty 


1992 


12,616 


7,879 


1,982 


2,233 


522 




1991 


12,204 


7,275 


2,123 


2,291 


515 


Surgical Specialty 


1992 


11,491 


2,835 


7,978 


631 


47 




1991 


11,981 


2,620 


8,651 


605 


105 


Other Medical 


1992 


4,960 


155 


1,973 


2,792 


40 


Specialty 


1991 


4,942 


145 


1,867 


2,875 


55 


Clinic/Unknown 


1992 


1,244 


620 


329 


259 


36 




1991 


1,680 


800 


453 


378 


49 


Chiropractor, Optometrists 


1992 


1,167 


625 


457 


42 


43 


and Podiatrists 


1991 


1,123 


577 


432 


48 


66 



SOURCE: HCFA Part B Monitoring System: HCFA National Claims History File. 



Table 1-3. Medicare Part B fee-for-service claims: Allowed charges by physician 
specialty category: 1991, 1992, and preliminary 1993. 





Allowed 


Percent 




Charges 


of Total 




in millions 




ALL PHYSICIANS 






1993 preliminar}/ 


$32,040 


100.0 


1992 


34,854 


100.0 


1991 


34,906 


100.0 


Primary Care Specialties 






1993 preliminary 


3,332 


10.4 


1992 


3,376 


9.7 


1991 


2,976 


8.5 


Medical Specialties 






1993 preliminary 


11,989 


37.4 


1992 


12,616 


36.2 


1991 


12,204 


35.0 


Surgical Specialties 






1993 preliminary 


10,442 


32.6 


1992 


11,491 


33.0 


1991 


11,981 


34.3 


Other MD Specialties 






1993 preliminary 


4,297 


13.4 


1992 


4,960 


14.2 


1991 


4,942 


14.2 


Clinics/Unknown 






1993 preliminary 


902 


2.8 


1992 


1,244 


3.6 


1991 


1,680 


4.8 


Chiropractors, Optometrists, 


and Podiatrists 




1993 preliminary 


1,078 


3.4 


1992 


1,167 


3.3 


1991 


1,123 


3.2 



SOURCE: HCFA Part B Monitoring System: HCFA National Claims History File. 



Table 1-4. Percent changes in Medicare Part B fee-for-service enrollees and allowed 
charges for physician services by geographic area, 1991-92 





Percent 


change 




Percent 


change 




1991 to 1992 




1991 to 1992 




Fee-for- 






Fee-for- 




Geographic 


service 


Allowed 


Geographic 


service 


Allowed 


Area 


Enrollment /I 


Charges /2 


Area 


Enrollment /I 


Charges /2 


TOTAL, All Areas 


1.677 


0.062 


West North Central 


1.378 


0.627 








Iowa 


0.588 


1.562 


United States 


1.619 


0.059 


Kansas 


2.110 


(0.977) 








Minnesota 


1.848 


1.928 


New England 


1.413 


0.785 


Missouri 


1.142 


0.554 


Connecticut 


1.265 


(2.846) 


Nebraska 


2.040 


(1.587) 


Maine 


2.343 


2.273 


North Dakota 


1.059 


2.326 


Massachusetts 


1.239 


2.038 


South Dakota 


0.818 


1.176 


New Hampshire 


3.406 


8.163 


Kentucky 


2.765 


1.124 


Rhode Island 


(0.139) 


0.000 


Mississippi 


1.618 


1.465 


Vermont 


1.303 


2.083 


Tennessee 


2.449 


2.545 


Middle Atlantic 


1.434 


2.576 


West South Central 


2.192 


(1.673) 


New Jersey 


1.724 


4.177 


Arkansas 


1.733 


(3.179) 


New York 


0.990 


1.870 


Louisiana 


2.964 


(3.559) 


Pennsylvania 


1.813 


2.597 


Oklahoma 


0.381 


(1.424) 








Texas 


2.518 


(0.876) 


South Atlantic 


2.227 


(0.190) 








Delaware 


5.075 


8.235 


Mountain 


2.001 


(0.143) 


Dist. of Columbia /3 


0.028 


1.478 


Arizona 


(0.071) 


(2.390) 


Florida 


1.270 


(2.807) 


Colorado 


2.459 


3.265 


Georgia 


3.020 


1.740 


Idaho 


2.375 


6.667 


Maryland 12 


2.715 


2.236 


Montana 


2.150 


2.410 


North Carolina 


2.930 


4.184 


Nevada 


5.509 


(4.124) 


South Carolina 


3.191 


4.142 


New Mexico 


3.103 


(3.200) 


Virginia /3 


2.426 


0.000 


Utah 


1.964 


6.731 


West Virginia 


1.771 


(0.855) 


Wyoming 


2.859 


4.167 


East North Central 


1.776 


2.002 


Pacific 


(0.191) 


(5.304) 


Illinois 


1.293 


1.370 


Alaska 


8.966 


(5.000) 


Indiana 


1.203 


4.574 


California 


(0.905) 


(6.426) 


Michigan 


2.455 


2.885 


Hawaii 


1.506 


(2.222) 


Ohio 


1.702 


0.066 


Oregon 


0.257 


0.364 


Wisconsin 


1.468 


3.770 


Washington 


4.712 


(0.567) 








Outlying & Foreign 


6.838 


0.391 








(Mainly Puerto Rico) 







1/ Calculations based on 31.7 million enrollees in 1992 and 31.2 million in 1991. 

2/ Excludes allowed charges from Railroad Retirement Board carrier. Calculations based on allowed charges of 

$34,854 billion in 1992 and $34,906 billion in 1991. 
3/ For District of Columbia, Maryland, and Virginia combined, fee-for-service enrollment increased 
by 2.411 percent and allowed charges increased by 1.277 percent. 



NOTE: Parentheses indicate negative number. 



SOURCES: 

- HCFA Part B Monitoring System: Enrollment calculations from June 30 Medicare Part B Enrollment Files. 

- HCFA Part B Monitoring System: Allowed charges calculations from HCFA National Claims History File. 



Table 1-5. Medicare Part B fee-for-service claims: Allowed charges for physician services by 
geographic area, 1991 and 1992 and preliminary 1992 and 1993 





Calendar Year 


Preliminary 1/ 




Calendar Year 


Preliminary 1/ 


Geographic 


1991 


1992 


1992 


1993 


Geographic 


1991 


1992 


1992 


1993 


Area 










Area 














(in millions) 








(in millions) 




Total All Areas 


$34,906 


534,854 


$30,594 


$32,040 


West North Central 


$2,072 


$2,085 


$1,859 


$1,924 












Minnesota 


363 


370 


331 


340 


RRB 


787 


713 


570 


612 @ 


Iowa 


320 


325 


292 


305 












Missouri 


722 


726 


638 


667 


New England 


1,784 


1,798 


1,596 


1,738 


North Dakota 


86 


88 


79 


77 


Maine 


132 


135 


120 


132 


South Dakota 


85 


86 


78 


80 


New Hampshire 


98 


106 


95 


103 


Nebraska 


189 


186 


166 


171 


Vermont 


48 


49 


44 


47 


Kansas 


307 


304 


275 


284 


Massachusetts 


834 


851 


746 


827 












Rhode Island 


145 


145 


129 


136 


East South Central 


1,943 


1,984 


1,758 


1,838 


Connecticut 


527 


512 


462 


493 


Kentucky 


445 


450 


404 


420 












Tennessee 


668 


685 


601 


618 


Middle Atlantic* 


6,699 


6,866 


5,880 


6,286 


Alabama 


557 


572 


502 


530 


New York 


2,888 


2,942 


2,505 


2,675 


Mississippi 


273 


277 


251 


270 


New Jersey 


1,245 


1,297 


1,118 


1,203 












Pennsylvania 


2,310 


2,370 


2,048 


2,159 


West South Central 


3,227 


3,173 


2,820 


2,876 


Puerto Rico* 


256 


257 


209 


249 


Arkansas 


346 


335 


303 


306 












Louisiana 


590 


569 


506 


525 


South Atlantic 


6,844 


6,831 


6,066 


6,402 


Oklahoma 


351 


346 


307 


319 


Delaware 


85 


92 


81 


86 


Texas 


1,940 


1,923 


1,704 


1,717 


Maryland 


466 


478 


398 


439 












Dist. of Columbi 


406 


412 


359 


376 


Mountain 


1,394 


1,392 


1,232 


1,262 


Virginia 


538 


538 


486 


521 


Montana 


83 


85 


75 


81 


West Virginia 


234 


232 


204 


211 


Idaho 


75 


80 


72 


77 


North Carolina 


716 


747 


651 


680 


Wyoming 


24 


25 


23 


24 


South Carolina 


338 


352 


318 


335 


Colorado 


245 


253 


220 


229 


Georgia 


747 


760 


674 


704 


New Mexico 


125 


121 


107 


113 


Florida 


3,313 


3,220 


2,895 


3,050 


Arizona 


544 


531 


472 


465 












Utah 


104 


111 


97 


103 


East North Centr 


5,443 


5,552 


4,878 


5,121 












Ohio 


1,513 


1,514 


1,335 


1,392 


Pacific 


4,713 


4,463 


3,935 


3,990 


Indiana 


634 


663 


587 


618 


Washington 


529 


526 


468 


457 


Illinois 


1,387 


1,406 


1,235 


1.287 


Oregon 


275 


276 


251 


244 


Michigan 


1,352 


1,391 


1,216 


1,296 


California 


3,797 


3,553 


3,122 


3,188 


Wisconsin 


557 


578 


505 


528 


Alaska 


21 


20 


17 


18 












Hawaii 


90 


88 


77 


83 



1/ The preliminary figures include only those bills received as of December 31. Note that for 1992, the preliminary 
figure was 87.78 percent of the ultimate calendar 1992 figure which was calculated for receipts through Jime 30, 1993. 

* Puerto Rico included with Middle Atlantic Region because it is part of the HCFA New York Regional Office. 
@ Includes approximately $2 million from claims processed by four regional carriers who process durable medical 
equipment claims. 

SOURCE: HCFA Part B Monitoring System: HCFA National Claims History File. 



Table 1-6. Medicare Part B fee-for-service claims: Allowed charges for physician services 
by place of service, 1991, 1992 and preliminary 1993 





1991 


1992 


Preliminary 


1993 


Place of Service 


Amount 
in millions 


Percent 


Amount 
in millions 


Percent 


Amount 
in millions 


Percent 


All 


$34,906 


100.0 


$34,854 


100.0 


$32,040 


100.0 


Office 


13,677 


39.2 


13,940 


40.0 


13,791 


43.0 


Home 


158 


0.4 


146 


0.4 


117 


0.4 


Hospital Inpatient 


13,986 


40.1 


13,210 


37.9 


11,393 


35.6 


HOPD or ER 


5,587 


16.0 


5,465 


15.7 


4,979 


15.5 


ASC 


493 


1.4 


669 


1.9 


698 


2.2 


Nursing Home 


518 


1.5 


677 


1.9 


649 


2.0 


All Other 


488 


1.4 


747 


2.1 


413 


1.3 



NOTES: HOPD is Hospital Outpatient Department. 
ER is Emergency Room. 
ASC is Ambulatory Surgical Center. 



SOURCE: HCFA Part B Monitoring System: HCFA National Claims History File. 



Appendix II 
Beneficiary Access and Utilization 



Prepared by: Paul W. Eggers, Ph.D. 

Office of Research and Demonstrations 

Health Care Financing Administration 

April 1994 

Revised May 31, 1994 



Appendix II 

Beneficiary Access and Utilization 

INTRODUCTION 

Because the physician payment reform (PPR) provisions of the Omnibus Bugdget 
Reconciliation Act (OBRA) of 1989 represent major changes in the method of paying 
physicians, both physician behavior and beneficiary access to care may be affected. 
This appendix presents information on access to care as measured by actual use of 
services. The data presented here update the baseline beneficiary data presented in 
the 1993 access report (HCFA, 1993) and provide the second year of post-MFS data 
from the beneficiary monitoring files. The data in this appendix include information 
from the 2 years preceding implementation of the MPS (calendar years 1990 and 
1991), final data from 1992, and preliminary data for 1993. With the exception of 
influenza vaccine, all analyses in this appendix are limited to services covered under 
the MPS, billed by both physicians and non-physicians. 

In general, the MPS has increased the price of medical services and decreased the 
price of surgical services. Higher prices for medical services should increase the supply 
of services furnished by providers for this type of care, thus increasing access to 
primary care. However, as noted by Mitchell (1990), increased prices will also increase 
related out-of-pocket expenses. Although the average beneficiary is expected to see 
little change in overall out-of-pocket expenses due to the MPS, about one in 10 
patients is expected to have a 20 percent or greater increase in out-of-pocket medical 
expenses. However, one out of seven black persons and persons living in rural areas 
will incur this level of increased out-of-pocket expense. This extra out-of-pocket 
burden could deter use of services. 

Lower prices for surgical services could also provide incentives to increase or decrease 
access to care. If lower prices cause physicians to increase volume, then more 
beneficiaries will receive these services. But if lower prices make Medicare 
beneficiaries less attractive clients for physicians, then physicians may shift more of 
their workload to non-Medicare populations. Price shifts could also have an impact on 
geographic variations in access, particularly if decreases in prices in urban areas make 
rural areas more attractive as practice sites for physicians. In short, the impact of 
MPS on beneficiary access to care cannot be predicted with any assurance. It is, 
therefore, important to monitor access for unexpected adverse utilization changes. 

Particular importance is attached to demographic variation in access to care. Many 
studies suggest that blacks use less ambulatory medical care than do whites, despite 
having higher mortality and morbidity rates (HCPA, 1990a; HCPA, 1990b; JAMA, 



Appendix II- 1 



1990; NCHS, 1990). Another population subgroup thought to be particularly 
vulnerable are the older elderly (those over age 85). Persons in rural areas are also 
disadvantaged relative to persons in urban areas, with respect to poverty, mortality 
rates, and measures of potential access such as physician to population ratios (Office 
of Technology Assessment (OTA), 1990; Hewitt, 1989). The analyses in this appendix 
focus on these population subgroups to continue the process of assessing changes in 
use patterns over time. 

This appendix focuses on overall trends in allowed charges by type of service; physician 
visits; and use of influenza vaccine in the Medicare population. Although the primary 
intent of the monitoring system is to examine use of services, the allowed charge data 
are important for understanding the fiscal magnitude of various types of services. 

Monitoring physician visits is particularly important for several reasons. First, physician 
visits in the ambulatory setting typically represent an individual's entry into the medical 
system. To the extent that Medicare beneficiaries have access to and use primary care 
physician services, they have entered the health care delivery system, and potentially 
have access to specialists and more advanced, procedural services. Second, evaluation 
and management services by physicians account for a large proportion of the total 
Medicare outlays for physician care. In 1990, these services accounted for 38.9 percent 
of the total allowed charges for physician services included in the MFS. Third, one of 
the aims of physician payment reform was to shift the weight of payments from the 
procedural types of care to the evaluation and management types of services. 

Influenza vaccination became a covered service in 1993 and represents one of the few 
preventive services paid for by Medicare. Virtually all persons can benefit from 
receiving an influenza vaccination. Therefore, measures of its use provide a reasonably 
good indication of preventive service use by Medicare beneficiaries. 

Trend data on physician visits are shown in several figures by demographic and 
geographic population subgroups for ambulatory visits only. That is, hospital visits are 
not included in the figures.' As primary access points, ambulatory visits are the most 
relevant type of physician visit. Because physician contacts in the inpatient setting are 
contingent on hospitalization, these visits are not as appropriate for measuring access 
to medical care. The inclusion of hospital visits (not shown) does not change the 
patterns displayed in the figures. 



' Because most consultations are in the inpatient setting. Figures II-2 through II-6 exclude both 
hospital and consultations. Special services are included in the ambulatory category, although some of 
these services (particularly pathology and psychiatry) take place in the inpatient setting. 



Appendix II-2 



It should be noted that the rates of physician visits described in this appendix may 
differ from those calculated using data from the Medicare Current Beneficiary Survey 
(MCBS) or from the National Health Interview Survey (NHIS). There are a number 
of differences in data collection methodologies, including the fact that the surveys 
report exclude persons living in long term care facilities. The administrative data used 
in this appendix cover all physician contacts, including those in long term care settings. 

METHODS 

Sources of Data 

Utilization data for this study were generated from two sources. Data for the years 
1990 and 1991 were taken from the Part B Medicare Annual Data (BMAD) 
beneficiary files. The beneficiary BMAD data provide detailed procedure level 
information on services received by a 5 percent random sample of Medicare 
beneficiaries. Whereas the 1990 BMAD file was created fi^om files submitted to 
HCFA by the Medicare carriers, the 1991 BMAD file was created by HCFA's Bureau 
of Data Management and Strategy directly from National Claims History (NCH) claims 
processed by staff responsible for maintenance of the Common Working File. Another 
difference between the 1990 and 1991 BMAD files is that the 1990 file was updated 
through March of 1991 while the 1991 BMAD was updated through June 1992. 
Therefore, it is likely that some differences in processing or reporting could inflate the 
changes in rates between 1990 and 1991.- The data for 1992 and 1993 come from the 
Part B beneficiary-based monitoring system and were compiled from the 100 percent 
NCH data base. This monitoring system is designed to have complete updates for 
12 months after the end of each quarter. For example, the January-March 1992 
quarter was updated through March 1993; the April-June 1992 quarter was updated 
through June 1993, and so on. Whereas the 1992 data presented in this appendix 
represent complete updates, the 1993 data are as yet incomplete.^ The data include all 
bills processed through December 1993. 

Denominators, based on mid-year enrollment, were developed from the Medicare 
beneficiary denominator files in order to calculate rates of physician visits per 1,000 



^ For example, the June 1993 update increased the volume of medical visits for 1992 by 1.5 percent 
over the March 1993 update. Therefore, the rates of increase between 1990 and 1991 reported in this 
chapter are likely to be overestimated. 

■^ Based on the first 8 quarters of the monitoring system updates, it is likely that the 1993 data are: 
99 percent complete for January to March, 97 to 98 percent complete for April to June, 90 to 95 percent 
complete for July to September, and 55 to 60 percent complete for the October to December period. Data 
for 1993 is probably between 85 and 90 percent complete. 



Appendix II-3 



beneficiaries. Persons belonging to a health maintenance organization (HMO) or a 
Health Care Prepayment Plan (HCPP) were excluded because they do not receive Part 
B services through fee-for-service claims. Denominator files were available for the 
years 1990, 1991, and 1992. Estimates of 1993 Medicare Part B eligible persons were 
made by inflating the 1992 population counts by the observed change between 1991 
and 1992. 

Type of Service Classification System 

Service coding is based on the HCFA Common Procedure Coding System (HCPCS). 
Current Procedural Terminology (CPT-4) codes represent the component of HCPCS 
for physicians' services. These codes are used for Part B billing purposes and are 
much too detailed (there are over 12,000 individual codes) for meaningful analysis of 
beneficiary use of services. For example, prior to 1993 there were nine different codes 
for coronary artery bypass graft (CABG) surgery based on the number of grafts and 
whether the graft is autogenous or nonautogenous. Such distinctions are important for 
payment purposes or for specific studies of CABG but are largely irrelevant for 
examining utilization differences across population subgroups. On the other hand, the 
broad type of service classifications available on the BMAD files (e.g., medical, 
surgical, and consultation) lack many clinical distinctions that may be important to 
track in a system designed to monitor beneficiary use of services. 

A type of service classification system, Berenson-Eggers type of service (BETOS), has 
been developed by researchers at the Urban Institute (Holahan, et al.) and staff in the 
Office of Research in HCFA. HCPCS codes have been categorized into 77 specific 
groupings representing all services covered under the MFS, with the expectation that 
variations in treatment can be tracked effectively with these distinctions. For example, 
including codes used prior to 1992 and codes introduced for 1993, there are 482 
separate HCPCS codes representing various types and levels of physician visits and 
consultations which have been grouped into 6 major types: office (including outpatient 
departments); hospital (inpatient only); emergency room; nursing home and home; 
special services; and consultation. A detailed description of the BETOS service 
classification system is shown in Technical Note A at the end of this Appendix." 

Geographic Classification 

The urban/rural classification used in this appendix is the Human Resource Profile 
County (HRPC) coding system established by the Office of Management and Budget 



'' The entire BETOS classification system includes all Part B services processed by Medicare carriers, 
including durable medical equipment, laboratory tests, drugs and ambulance services. There are 105 
categories in all. However, only the 77 specific to the Medicare Fee Schedule are covered in this appendix. 



Appendix II-4 



based on work conducted at the Department of Agriculture. It classifies metropolitan 
statistical areas (MSA) into large core, fringe, medium, and small. The non-MSA 
areas are divided into urban, lesser urban, and thinly populated areas. Each of these 
nonmetropolitan areas is further divided into areas adjacent to and not adjacent to 
metropolitan areas. In their overview of urban/rural designations, the Office of 
Technology Assessment (OTA) recommended this typology as perhaps the best for 
assessing issues of access to medical care (OTA, 1990). All the data processed 
through 1993 are based on the 1980 HRPC groupings. The Census Bureau has 
recategorized about 600 counties based on 1990 census data. Beginning in 1994, the 
monitoring system will use the new groupings. This typology is described in Technical 
Note B. 

An additional geographic grouping of States was developed based on the expected 
impact of the MFS. Because the MFS replaced the carrier-specific rates with a 
national system in which regional variation will be based only practice costs, the 
average change in price for physician services will vary considerably across areas of the 
country. The expected impact of these price changes by State was published in the 
November 25, 1991, Federal Register Vol. 56(227). Accordingly, State "Ex Ante 
impact" areas were defined based on the estimated price impact of the MFS. States 
were grouped according to the overall estimated change in average Medicare physician 
prices (compared to what prices were expected to have been without the MFS) by 
1996 as follows: (1) Increase (-1-4 percent to -1-12 percent); (2) No Change (-1-3 
percent to -3 percent); (3) Moderate decrease (-4 percent to -9 percent); and (4) 
Large Decrease (-10 percent to -20 percent). A listing of the States and their position 
in the Ex Ante classification is presented in Technical Note C. 

RESULTS 

Total Allowed Charges for Services Covered under the MFS 

In 1990, allowed charges for physician services covered under the MFS totaled $29.9 
billion (Table II-l). Allowed charges increased by 10.4 percent to $33.0 biUion in 1991, 
but decreased by 0.8 percent (to $32.8 billion) in 1992.^ Rates of change varied greatly 
by broad type of service. Allowed charges for visits and consultations increased by 8.2 
percent in 1992 (less than the 14.1 percent increase from 1990 to 1991). Allowed 
charges for procedures decreased by 9.1 percent in 1992 (more than offsetting the 8.8 
percent increase in 1991) resulting in nominal charges for 1992 that were lower than in 
1990 ($13.8 bilhon and $13.9 billion, respectively). Allowed charges for imaging 



^ Appendix I showed a 2.4 percent increase in fee for service allowed charges between 1991 and 1992. 
However, the figures in Appendix I include services not covered by the MFS. The monitoring system shows 
an 8.2 percent increase in non-MFS covered services. 



Appendix II-5 



services increased slightly in 1992 (0.3 percent) following a 5.5 percent increase from 
1990 to 1991. As a result of these trends, there has been a marked shift in charges by 
broad type of service. This is shown in Table II- 1 and displayed graphically by quarter 
in Figure II- 1. The share of physician allowed charges accounted for by imaging in 
1990 was 14.7 percent and by 1992 had declined slightly to 14,2 percent. There has 
been a decided shift in charges from the procedure categories to the medical visit 
category. In 1990, procedures accounted for 46.5 percent of allowed charges while 
medical visits accounted for 38.9 percent. By 1992, the share of Medicare allowed 
charges accounted for by medical visits increased to 43.8 percent with corresponding 
decreases in the share accounted for by procedures (42.0 percent in 1992). 

As can be seen in Table II- 1 and Figure II-l, this shift from the procedure to the visit 
category appears to be continuing in 1993. As Figure II-l shows, these changes were 
not gradual but occurred abruptly in the first quarter of 1991, 1992, and 1993, 
reflecting payment changes.^ 

Table II-2 shows the distribution of allowed charges for visits and consultations for the 
years 1990 through 1993. Allowed charges for office visits increased by 6.7 percent in 
1992 following a 16.9 percent increase in 1991. Allowed charges for hospital visits 
increased by 2.7 percent in 1992. However, part of this low rate of increase was due 
to a payment policy change in 1992 which shifted a large number of services from the 
hospital critical care area (53.9 percent decrease in 1992) to the category of 
consultations (30.1 percent increase in 1992). Although there was an 8.4 percent 
increase in allowed charges for specialist visits, it varied considerably by type of 
specialty. Allowed charges for psychiatric visits increased by 31.8 percent^ and 
ophthalmology visits decreased by 6.6 percent. 

Table II-3 presents allowed charges for procedures. Almost all categories showed 
declines in allowed charges from 1991 to 1992. The largest decrease was for 
electrocardiograms, -65.8 percent. This was due to a change in the payment for 
electrocardiograms. In 1992 and 1993, Medicare allowed separate payment for the 
technical component for these procedures. The professional component was not billed 
separately but was bundled in the relative value for visit codes. Other procedures for 



^ As noted above, the 1993 data are still incomplete. However, a comparison of 1992 MFS services 
updated through December 1992 with 1993 MFS services updated through December 1993 shows a 6.4 
percent increase in allowed charges. This estimate will increase if bill processing has been slower in 1993 
than in 1992 and will decrease if bill processing was faster in 1993 than in 1992. 

^ Beginning in 1992, payment for services provided by psychologists was expanded to all treatment 
settings, not just inpatient. Increases in psychiatric services are apparently due, in part, to a continuation 
of expanded psychologist services. 



Appendix II-6 



which there was a 20 percent or greater decrease in allowed charges included 
cholecystectomy (-30.8 percent),* hysterectomy (-26.9 percent), treatment of retinal 
lesions (-21.7 percent), and laryngoscopy (-23.4 percent). There were increases in 
allowed charges in 1992 for minor procedures (4.3 percent) and oncology services (11.1 
percent). The increase for minor procedures could be due in part to the addition of 
some procedures which previously had been billed under non-MFS codes. 

Allowed charges for imaging services are shown in Table II-4. In 1992, standard 
imaging showed moderate decreases in allowed charges in all categories except for 
nuclear medicine which increased by 6.5 percent. Allowed charges for advanced 
imaging increased by 4.3 percent overall. However, there were decreases for 
computerized axial tomography (CAT) scans and increases for magnetic resonance 
imaging (MRI) imaging, particularly MRI of the brain which increased by 45.3 percent. 
Sonography increased by 6.6 percent, largely driven by the 8.9 percent increase for 
echography of the heart. There was also a 30.2 percent increase in the relatively small 
category of prostate sonography (from $17 million in 1991 to $22 million in 1992). 

Ambulatory Physician Visits per 1,000 Persons 

Last year's Report to Congress presented detailed baseline data (1990) on rates of 
physician visits per 1,000 persons by demographic and geographic categories. That 
analysis will not be repeated here but will be briefly summarized. Aged Medicare 
beneficiaries average about 10.5 physician visits per year with about 70 percent of 
these visits occurring in ambulatory settings. Ambulatory visit rates increase with age, 
females have higher visit rates than males, and blacks have lower visit rates than do 
whites. Ambulatory visit rates are highest in the West and lowest in the Northeast 
region of the country. Use rates are about 13 percent higher in metropohtan areas 
than in rural areas. Within metropolitan areas, use rates are highest in the large core 
counties. There is not much difference in physician visit rates in nonmetropolitan 
areas based on degree of urbanization or proximity to a metropolitan area. All three 
counties selected for tracking have higher than average use rates (Manhattan - 
one-third higher, Los Angeles - one-half higher, Dade County, Florida - two-thirds 
higher). Finally, among the PPR Ex Ante impact areas, physician visit rates are about 
16 percent higher in the States with large anticipated decreases than in the other 
States. 



* Part of this decrease was due to a shift in procedure to laparoscopic cholecystectomy, one of the few 
procedural categories to show an increase (2.1 percent) in allowed charges in 1992. 



Appendix II-7 



Quarterly Trends in Ambulatory Physician Visits per 1,000 Persons 

From 1986 through 1990, physician visits increased in virtually all categories (HCFA, 
1992). During this time, the number of physician office visits per 1,000 persons 
increased by 17.3 percent (about a 4.1 percent annual rate of increase). Inpatient 
hospital visits increased by 8.5 percent, emergency room visits increased by 25.5 
percent, nursing home/home visits increased by 10.4 percent, special service visits 
increased by 44.5 percent, and consultations increased by 6.5 percent. 

This upward trend in utilization continued in 1991 (data not shown). Total ambulatory 
physician visits (all ages) per 1,000 increased from 6,896 in 1990 to 7,600 in 1991, an 
increase of 10.2 percent. In 1992, the ambulatory physician visit rate increased to 7,698, 
a small increase of 1.3 percent. It is not yet certain what changes in physician visit 
rates will be for 1993. Based on estimates of the presumed lag in billing through 
December 1993, final 1993 physician visit rates could be as much as 5 percent greater 
than in 1992, a rate of increase more in line with historical trends. 

In order to track the relative use rates by demographic and geographic categories, 
quarterly use rates were calculated for each of the 14 quarters from 1990 through the 
2nd quarter of 1993. Because data subsequent to June 1993 are estimated to be less 
than 95 percent complete, it was decided not to include these quarters in the following 
analyses. However, even the rates for the first two quarter of 1993 will increase 
slightly as further updates become available. 

Ambulatory physician visit rates per 1,000 by age are shown in Figure II-2. Relative to 
persons ages 65 to 74, persons ages 75 to 84 had 24 to 38 percent more ambulatory 
physician visits and persons age 85 and over had between 61 and 88 percent more 
visits. All three age groups showed similar trends from 1990 through the first half of 
1993. 

Figure II-3 shows the number of ambulatory physician visits per 1,000 persons by 
quarter for black and white aged Medicare beneficiaries. Throughout the 14 quarters 
shown, the physician visit rate varied from 1,800 to 2,100 per quarter for white persons 
and from 1,500 to 1,800 for black persons. Overall, the relative use rates were stable. 
In 1990 the ratio of ambulatory physician visits per 1,000 for black persons compared 
to white persons was 0.88. In 1991, 1992, and for the first half of 1993, the ratio was 
0.87. 

Figures II-4, II-5, and II-6 show trends in ambulatory physician visits per 1,000 persons 
by various geographical categories. Unlike the rates for aged beneficiaries in Figures 
II-2 and II-3, these rates are based on the entire Medicare population, including the 
disabled and persons with ESRD. In Figure II-4, shows these rates for (1) large core 



Appendix II-8 



areas within metropolitan areas (2) other metropolitan counties, (3) nonmetropolitan 
counties adjacent to metropolitan areas, (4) nonmetropolitan counties not adjacent to 
metropolitan areas. All types of areas showed similar trends throughout this time 
period with the highest rates in the metropolitan areas and very similar rates in both 
adjacent and nonadjacent nonmetropolitan areas. There was a slight increase in the 
metropolitan/nonmetropolitan differential during these years. Compared to large core 
metropolitan areas, adjacent and nonadjacent metropolitan areas had lower relative use 
rates in 1991 and 1992 than in 1990. However, the relative use rates for 
nonmetropolitan areas increase slightly in 1993. 

Use rates by PPR Ex Ante impact areas are shown in Figure II-5. States in which 
physician payments prices are expected to increase (relative to the old system) are 
used as the comparison group. States categorized as "no change" (within 3 percent 
plus or minus) have physician visit use rates about 3 to 4 percent lower than States 
with expected price increases in 1990 and 1991. However, in 1992 and the first half of 
1993, use rates in the "no change" States were 7 to 9 percent lower than in States 
expected to have increases. States expected to have a moderate decrease in physician 
prices had rates very nearly the same as the "increase" States, and this also remained 
relatively stable through the first half of 1993. The highest use rates occurred in the 
States where prices are expected to have the largest decreases, about 10 to 17 percent 
higher than increase States in all the years under observation. All these physician use 
rates showed basically the same trends as the national average. 

The three counties selected for special observation all maintained their high 
ambulatory physician visit rates during these years (Figure II-6). Compared to national 
use rates, residents of Dade County had 62 to 68 percent more ambulatory physician 
visits per 1,000 throughout the 1990 to 1993 time period. Similarly, residents of Los 
Angeles County maintained use rates at about 40 percent over the national average. 
Use rates in Manhattan were about 33 to 37 percent higher than nationally in 1990 
through 1992. However, in the first half of 1993 these rates dropped slightly to 
27 percent over the national average. Further trend data will be necessary to 
determine if this is a short deviation or a change in patterns of use. 

Influenza Vaccinations per 100 Persons 

Influenza vaccinations became a covered service for Medicare beneficiaries beginning 
on May 1, 1993. It is hoped that most beneficiaries will avail themselves of this 
inexpensive preventive service. The vaccine itself is billed under HCPCS 90737. The 
code for the administration of the flu vaccine is Q0124. Prior to 1994, the monitoring 
system did not include a separate BETOS listing for influenza immunization. However, 
code Q0124 was available for separate tabulation. Because the vaccine could be given 



Appendix II-9 



by nonphysician health personnel and was available through public health clinics, the 
following statistics represent a lower limit estimate of the use of the influenza vaccine.^ 

Table II-5 shows the number of influenza immunizations (as measured from the 
administration code Q0124) by basic demographic and geographic categories for 1993. 
For aged persons the rate is 25.1 per 100 persons. This does not vary greatly by age 
with the highest rate for age 75 to 84 years (27.0) and the lowest for age 65 to 74 
years (23.9). Men and women had identical rates of 25.1. However, there is a striking 
age effect by sex. Older men are more likely than younger men to have gotten the flu 
vaccine whereas use rates decreased among women over the age of 85. There is also 
a marked black/white differential with 11.2 for blacks and 27.3 for whites. Unlike the 
case for whites, there was a sex difference among blacks (9.9 for men and 12.0 for 
women, not shown). The decreasing use of flu vaccine by age occurred only for white 
women. The rate for black women was about the same for all age groups. 

The rate was considerably lower among the disabled at 9.8 per 100 persons. Here the 
age effect was more pronounced, tripling from the 4.8 among persons to 44 years to 
15.0 among persons 55 to 64 years. Disabled men had lower rates than disabled 
women (8.5 and 11.8, respectively). Again the black/white differential was evident (4.6 
for blacks arid 11.2 for whites). The rate for persons with end-stage renal disease 
(ESRD) seems particularly low considering how often they are in contact with health 
providers. However, it may be that their rate (and perhaps the rate for blacks) is 
biased downward by nonphysicians giving the injections. 

The overall national rate for aged and disabled persons combined was 23.0 per 
100 persons (Table II-6). It was lowest in the Northeast (20.7) and highest in the 
Midwest (26.3). It was well below 20 percent in each of the three metropolitan areas 
selected for tracking, Manhattan, Los Angeles, and Dade County. This may be driven 
by the high black composition of the cities and may also be influenced by access to the 
vaccine through public health clinics. Use rates were fairly consistent across the 
urban/rural spectrum. 

There were differences in flu vaccine use rates by PPR Ex Ante impact State 
designations. The highest rate was in those States where PPR is expected to reduce 
physician prices the most (38.9 percent). It is lowest in those States expecting 
increases in prices (14.1 percent). It could be that these impact areas are highly 
correlated with socioeconomic status. The wealthy States are where the cuts are most 



' The monitoring system has been revised to include a full count of HCPC 90737 so that demographic 
and geographical variation in its use can be reported in future reports to Congress. 



Appendix 11-10 



likely to occur and the poor States are where the increases are expected to go. It is 
likely that the wealthy States also have higher rates of use of preventive services. 

It should be reiterated that the vaccination rates shown in Tables II-5 and II-6 are 
underestimates of the total influenza vaccinations received by the Medicare population. 
The data are based only on the administration component of this service. Therefore, 
differences in use rates across age, sex, race and geographic categories may not be as 
great as indicated above. Data currenly being collected for 1994 will not have this 
problem. 

DISCUSSION 

The first year of the MFS showed a distinct change from the historical trends in 
Medicare payments for physician services. From 1980 to 1990, per capita Medicare 
payments for physician and related services had been increasing at an annual rate of 
9.0 percent (Helbing, 1993). The increase in allowed charges per capita from 1990 to 
1991 was 10.4 percent. In 1992, the increase was less than one percent. Thus, the 
first year of the MFS was associated with a break in the historical increase in physician 
payments. Allowed charges for visits and consultations increased by 8.2 percent while 
allowed charges for procedures decreased by 9.1 percent. Although data for 1993 are 
incomplete, it appears that the shift in payments from procedural to the visit and 
consultative services is continuing in the second year of the program. 

Data for 1992 also represented a break in the historical trend in ambulatory physician 
visits per 1,000 persons. In the late 1980s, ambulatory physician visit rates for 
Medicare beneficiaries had been increasing by about 4.1 percent per year, ranging from 
3.7 percent to 6.1 percent. There was a jump of 10.2 percent in 1991 and a modest 
increase of 1.3 percent in use rates in 1992. Neither the large increase in 1991 nor the 
low increase in 1992 are consistent with earlier trends and the reasons for the changes 
are unknown. The reasons for the increase in 1991 is not known. However the low 
rate of increase in 1992 may be due in part to the effect of bundling services into 
global surgery periods. Demographic and geographic differences in use rates have 
remained fairly constant through the second quarter of 1993. Thus, it appears that in 
the first 2 years of MFS implementation, general access to physician services has 
remained essentially unchanged for Medicare beneficiaries. 



Appendix 11-11 



REFERENCES 

Council Report: "Black- White Disparities in Health Care." Journal of the American 
Medical Association 263 (17): 2344-2346. 

Health Care Financing Administration: Third Annual Report to Congress: "Utilization 
and Access to Care," May 1993. 

Health Care Financing Administration: Special Report. Volume 1, Hospital Data bv 
Geographic Area for Aged Medicare Beneficiaries: Selected Diagnostic Groups. 1986 
HCFA Pub. No. 03300, June 1990. 

Health Care Financing Administration: Special Report, Volume 2, Hospital Data bv 
Geographic Area for Aged Medicare Beneficiaries: Selected Procedures. 1986 HCFA 
Pub. No. 03300, June 1990. 

Helbing, C, and J. Petrie: "Supplementary Medical Insurance Benefit for Physician and 
Supplier Services." Health Care Financing Review, 1992 Annual Supplement . October 
1993. 

Hewitt, M.: Defining "Rural" Areas: Impact on Health Care Policv and Research. OTA 
Staff Paper. Washington, D.C. U.S. Government Printing Office, July 1989. 

Holahan, J. et al.: "Trends in Access to Physician Services" Urban Institute Policy 
Center task, in progress. 

Mitchell, J., and T. Menke: "How the Physician Fee Schedule Affects Medicare 
Patients' Out-of-Pocket Spending," Inquiry , 27(Summer), 108-113. 1990. 

National Center for Health Statistics: "Advance Report of Final Mortality Statistics, 
1988," Monthlv Vital Statistics Report Vol. 30 (7), 1990. 

U.S. Congress, Office of Technology Assessment: Health Care in Rural America. Pub. 
No. OTA-H-434. Washington, D.C. U.S. Government Printing Office, September 1990. 



Appendix 11-12 



Figure II-l 

Allowed Charges - MFS Physician Services 
1990 to 1993, by Quarter 
All Medicare Beneficiaries 



Percent ot Total Allowed Charges 



60% 



50% - 

40%- 
30%- 
20% - 
1 0% - 



0% 



H r 



>4=T 



^i ^ ^ ^1^ ^ ^ ■¥: ^ ^ m ^1^ i^. ^ ^1^ ^ ^i 



I I I 1 1 1 1 1 1 1 I 1 1^— 

1234123412341234 
1990 I 1991 I 1992 I 1993 



-^■Visits/Consults +Procedures ^Imaging 



Figure II-2 

Ambulatory Physician Visits per 1,000 Persons 

1990 to 1993, by Quarter, by Age 

Medicare Beneficiaries Ages 65 and over 



visits per 1,000 Persons 



3,200 - 



2,700 - 



2.200- 



1.700- 



1.200 




2 3 4 12 

1992 I 1993 



-^ 65 to 74 + 75 to 84 "* 85 + 



Sources: 1990 and 1991 - 5 percent BMAD; HCFA Part B Beneficiary Monitoring 

System for 1992 and 1993 (updated through December 1993). 



Figure II-3 

Ambulatory Physician Visits per 1,000 Persons 

1990 to 1993, by Quarter, by Race 

Medicare Beneficiaries Ages 65 and over 



Visits per 1,000 persons 



2.400 




-*- White + Black 



Figure II-4 

Ambulatory Physician Visits per 1,000 Persons 

1990 to 1993, Large Core/Other, by Quarter 

All Medicare Beneficiaries 



Visits per 1,000 Persons 



2.400 



1.200 




— I 1 1 1 1 1 1 1 1 1 1 1 — 

12341234123412 
1990 I 1991 I 1992 I 1993 



■^Metro, Large Core +Metro, Other ^Non Metro, Ad] ♦Non Metro. Non Adj 



Sources: 1990 and 1991 - 5 percent BMAD; HCFA Part B Beneficiary Monitoring 

System for 1992 and 1993 (updated through December 1993). 



Figure II-5 

Ambulatory Physician Visits per 1,000 Persons 

1990 to 1993, by PPR Ex Ante Impact Area, by Quarter 

All Medicare Beneficiaries 



Visits per 1,000 Persons 



2.400 



1.200 




1 : 1 1 1 1 1 1 1 1 1 

12341234123412 
1990 I 1991 I 1992 I 1993 



"^Increase -r No Change ^Moderate Decrease •*" Large Decrease 



Figure II-6 

Ambulatory Physician Visits per 1,000 Persons 

1990 to 1993, by County, by Quarter 

All Medicare Beneficiaries 



Visits per 1,000 Persons 




-^■National +Manhattan ^ Dade County -■- Los Angeles 



Sources: 



1990 and 1991 - 5 percent BMAD; HCFA Part B Beneficiary Monitoring 
System for 1992 and 1993 (updated through December 1993). 



Table n-1. Medicare Part B fee-for-service claims: Allowed charges for physician 
services covered by the Medicare fee schedule, by major type of service 
category: 1990-93 



Service Category 


1990 


1991 


1992 


1993 /I 


1990-91 1991-92 






Allowed charges 


in millions 




Percent change 


Total 


$29,922 


$33,038 


$32,775 


$30,283 


10.4 -0.8 


Visits and Consultations 


11,631 


13,276 


14,371 


13,811 


14.1 8.2 


Procedures 


13,902 


15,132 


13,760 


12,249 


8.8 -9.1 


Imaging 


4,389 


4,629 


4,644 


4,224 


5.5 0.3 



Percent distribution 



Total 



100.0 



100.0 



100.0 



100.0 



Visits and Consultations 


38.9 


40.2 


43.8 


45.6 


Procedures 


46.5 


45.8 


42.0 


40.4 


Imaging 


14.7 


14.0 


14.2 


13.9 



1/ Preliminary data for 1993. 



SOURCES: 5 percent BMAD for 1990 and 1991; 

HCFA Part B Monitoring System (Updated through December 1993) for 1992 and 1993. 



Table n-2: Medicare Part B fee-for-service claims: Allowed charges for physician services 
covered by the Medicare fee schedule for visits and consultations: 1990 to 1993 



Service Category 


1990 


1991 


1992 


1993 /I 


1990-91 


1991-92 






AUowed charges 


in millions 




Percent 


change 


Total 


$11,631 


$13,276 


$14,371 


$13,811 


14.1 


8.2 


Office Visits 


4,027 


4,706 


5,023 


4,989 


16.9 


6.7 


New 


471 


550 


574 


554 


16.7 


4.3 


Established 


3,556 


4,157 


4,449 


4,435 


16.9 


7.0 


Hospital Visits 


3,725 


4,007 


4,116 


3,788 


7.6 


2.7 


Initial 


628 


680 


713 


694 


8.2 


4.9 


Subsequent 


2,549 


2,721 


3,123 


2,835 


6.8 


14.8 


Critical Care 


548 


606 


279 


260 


10.6 


-53.9 


Emergenay Room 


483 


610 


645 


662 


26.1 


5.8 


Home/Nursing Home 


419 


493 


554 


544 


17.7 


12.3 


Home 


56 


60 


53 


50 


7.4 


-11.2 


Nursing Home 


363 


433 


501 


493 


19.3 


15.5 


Special services 


1,711 


2,026 


2,196 


2,127 


18.4 


8.4 


Pathology 


490 


565 


636 


581 


15.3 


12.5 


Psychiatry 


348 


498 


656 


648 


43.0 


31.8 


Ophthalmology 


821 


899 


840 


838 


9.6 


-6.6 


Other 


52 


65 


65 


61 


24.6 


-0.3 


Consultation 


1,094 


1,242 


1,616 


1,503 


13.6 


30.1 


Chiropractic 


173 


191 


221 


197 


10.6 


15.9 



1/ Preliminary data for 1993. 



SOURCES: 5 percent BMAD for 1990 and 1991; 

HCFA Part B Monitoring System (Updated through December 1993) for 1992 and 1993. 



Table 11-3: Medicare Part B fee-for-service claims: Allowed charges for physician services 
covered by the Medicare fee schedule for procedures: 1990-93 



Service cateeorv 


1990 


1991 


1992 


1993 /I 


1990-91 


1991-92 






Allowed charges 


in millions 




Percent 


change 


Total 


$13,902 


$15,132 


$13,690 


$12,067 


8.8 


-9.5 


Major Procedure: General 


1,704 


1,690 


1,496 


1,273 


-0.8 


-11.5 


Breast 


70 


71 


59 


51 


1.4 


-17.6 


Colectomy 


182 


172 


148 


131 


-5.4 


-14.1 


Cholecystectomy 


142 


90 


62 


48 


-36.4 


-30.8 


TURP 


233 


221 


161 


132 


-5.1 


-26.9 


Hysterectomy 


45 


51 


53 


44 


14.4 


2.2 


Disk Surgery 


151 


170 


164 


146 


12.5 


-3.3 


Other 


881 


914 


848 


721 


3.7 


-7.2 


Major Procedure: Cardiovascular 


1,811 


1,890 


1,773 


1,553 


4.3 


-6.2 


CABG 


569 


549 


493 


424 


-3.5 


-10.2 


Aneurysm 


80 


76 


64 


57 


^.4 


-16.5 


Thromboendarterectomy 


76 


88 


81 


73 


15.8 


-8.4 


PTCA 


163 


220 


216 


188 


34.5 


-1.9 


Pacemaker 


130 


123 


110 


94 


-5.0 


-10.9 


Other 


793 


833 


810 


716 


5.0 


-2.8 


Major Procedure: Orthopedic 


1,009 


1,069 


1,001 


914 


5.9 


-6.3 


Hip Fracture Repair 


239 


245 


229 


202 


2.5 


-6.5 


Hip Replacement 


234 


239 


201 


180 


2.1 


-16.1 


Knee Revision 


242 


271 


262 


248 


11.9 


-3.3 


Other 


295 


314 


310 


284 


6.7 


-1.3 


Major Procedure: Eye 


2,527 


2,930 


2,530 


2,205 


15.9 


-13.7 


Corneal Transplant 


43 


45 


36 


32 


4.1 


-18.5 


Cat Rem/Lens Insert 


1,579 


1,813 


1,584 


1,351 


14.9 


-12.7 


Retinal Detachment 


66 


72 


59 


52 


8.3 


-17.7 


Treatm Retinal Lesions 


172 


188 


147 


155 


9.0 


-21.7 


Other 


667 


812 


704 


615 


21.8 


-13.4 


Ambulatoty Procedures: 


1,164 


1,286 


1,144 


1,018 


10.5 


-11.0 


Skin 


446 


501 


452 


397 


12.2 


-9.8 


Musculoskeletal 


178 


199 


173 


150 


11.6 


-13.1 


Hernia Repair 


81 


77 


64 


59 


-5.4 


-16.3 


Lithotripsy 


22 


22 


20 


19 


-1.3 


-9.1 


Other 


436 


487 


435 


394 


11.8 


-10.7 


Minor Procedures: 


1,181 


1,348 


1,406 


1,336 


14.1 


4.3 


Skin 


586 


648 


699 


690 


10.5 


7.9 


Musculoskeletal 


178 


198 


190 


180 


11.4 


AA 


Other 


416 


502 


517 


465 


20.5 


3.1 


Oncology 


618 


719 


799 


710 


16.3 


11.1 


Radiation Therapy 


526 


600 


685 


590 


14.1 


14.1 


Other 


92 


119 


114 


120 


28.7 


-3.7 


Endoscopy 


1,442 


1,657 


1,503 


1,391 


14.9 


-9.3 


Arthroscopy 


67 


79 


76 


74 


18.6 


-3.7 


Upper GI Endoscopy 


382 


442 


398 


354 


15.6 


-9.9 


Sigmoidoscopy 


120 


121 


98 


82 


1.0 


-19.1 


Colonoscopy 


468 


497 


451 


420 


6.3 


-9.3 


Cystoscopy 


238 


260 


238 


223 


9.1 


-8.5 


Broncoscopy 


86 


94 


80 


67 


9.6 


-15.3 


Laparoscopic Cholecystectomy 


4 


74 


76 


83 


2006.9 


2.1 


Laryngoscopy 


38 


42 


32 


36 


10.4 


-23.4 


Other 


40 


48 


54 


53 


20.4 


12.8 


Dialysis 


143 


164 


162 


136 


14.2 


-1.0 


Tests 


1,001 


988 


572 


411 


-1.3 


-42.2 


Other 


48 


54 


68 


75 


12.6 


25.9 


Electrocardiograms 


618 


590 


202 


210 


^.5 


-65.8 


Cardiov Stress Tests 


144 


159 


207 


157 


10.9 


29.9 


EKG Monitoring 


192 


185 


165 


152 


-3.2 


-10.7 


Anesthesia 


1,301 


1,392 


1,305 


1,119 


7.0 


-6.2 



1/ Preliminary data for 1993. 

SOURCES: 5 percent BMAD for 1990 and 1991; 

HCFA Part B Monitoring System (Updated through December 1993) for 1992 and 1993. 



Table n-4: Medicare Part B fee-for-service claims: AUowed charges for physician 
services covered by Medicare fee schedule, imaging services: 1990-93 



Service Category 


1990 


1991 


1992 


1993 /I 


1990-91 


1991-92 






Allowed charges 


in millions 




Percent 


change 


Total 


$4,389 


$4,629 


$4,644 


$4,224 


5.5 


0.3 


Standard Tmaging 


1,889 


1,937 


1,859 


1,658 


2.6 


-4.0 


Chest 


583 


578 


562 


455 


-0.7 


-2.8 


Musculoskeletal 


446 


432 


424 


363 


-3.1 


-1.9 


Breast 


169 


193 


192 


156 


13.9 


-0.2 


GI Tract 


190 


177 


171 


126 


-6.4 


-3.5 


Nuclear Medicine 


286 


331 


352 


363 


15.8 


6.5 


Other 


216 


226 


222 


195 


4.6 


-1.8 


Advanced Imaging 


868 


893 


931 


843 


2.9 


4.3 


Cat Scan - Head 


202 


194 


171 


147 


-3.9 


-11.8 


Cat Scan -Other 


411 


426 


411 


365 


3.8 


-3.6 


MRI - Brain 


112 


111 


162 


154 


-0.2 


45.3 


MRI - Other 


143 


161 


187 


177 


12.4 


16.5 


Sonography 


979 


1,069 


1,140 


1,126 


9.2 


6.6 


Echo-Eye 


103 


97 


103 


88 


-6.6 


6.9 


Echo-Abdomen/Pelvi 


191 


200 


191 


179 


4.5 


-4.1 


Echo- 


496 


569 


620 


635 


14.6 


8.9 


Carotid Artery 


127 


139 


131 


125 


9.3 


-5.2 


Prostate 


16 


17 


22 


20 


8.5 


30.2 


Other 


46 


49 


72 


79 


5.9 


48.1 


Imaging/Procedure 


653 


730 


714 


597 


11.8 


-2.2 


Proc, Incl Card Cath 


454 


528 


543 


449 


16.3 


3.0 


Proc Other 


199 


202 


170 


148 


1.7 


-15.8 



1/ Preliminary data for 1993. 



SOURCES: 5 percent BMAD for 1990 and 1991; 

HCFA Part B Monitoring System (Updated through December 1993) for 1992 and 1993. 



Table n-5: Influenza immunizations per 100 persons for aged and disabled 
Medicare beneficiaries, by gender and race: 1993 









Aged beneficiaries 






Gender 














and race 


All Ages 


65; 


-74 vrs. 


75- 


84 vrs. 


85+ vrs. 


All Persons 


25.1 




23.9 




27.0 


25.3 


Men 


25.1 




23.0 




28.3 


30.1 


Women 


25.1 




24.6 




26.2 


23.6 


White 


27.3 




26.3 




29.0 


26.7 


Black 


11.2 




10.4 




12.3 


12.5 



Disabled beneficiaries 





All Ages 


0-44 


yrs. 


45-54 


I yrs. 


55- 


-64 vrs. 


All Persons 


9.8 




4.8 




9.1 




15.0 


Men 


8.5 




4.1 




7.8 




13.4 


Women 


11.8 




6.0 




11.1 




17.3 


White 


11.2 




5.7 




10.2 




16.6 


Black 


4.6 




1.9 




4.5 




7.6 



NOTES: Immxmization counts are based only on the administration component, HCPCS=Q0124. 
A complete enumeration would include the vaccine itself, HCPCS=90737. 



Source: HCFA Part B Administrative Data through December 1993. 



Table n-6. Influenza immunizations per 100 persons (aged and disabled 
beneficiaries), by geographic area: 1993 





Services per 


Geographic Area 


100 Persons 


All Areas 


23.3 


Northeast 


20.7 


Midwest 


26.3 


South 


23.7 


West 


22.2 


Urban/Rural 




Metropolitan 


22.5 


Large Core 


18.2 


Large Fringe 


23.2 


Medium 


24.8 


Small 


26.4 


Non-Metropolitan 


25.0 


Urbanized - Adjacent 


25.0 


Urbanized - Not Adjacent 


25.9 


Less Urban - Adjacent 


24.1 


Less Urban - Not Adjacent 


26.5 


Thinly Pop. - Adjacent 


22.2 


Thinly Pop. - Not Adjacent 


23.4 


PPR Ex Ante 




Large Decrease 


38.9 


Moderate Decrease 


22.6 


No Change 


24.6 


Increase 


14.1 


Manhattan, NY 


15.9 


Dade County, Fla 


16.5 


Los Angeles, Ca 


12.1 



NOTES: Immunization counts are based only on the administation component, HCPCS=Q0124. 
A complete enumeration would include the vaccine itself, HCPCS=90737. 



SOURCE: HCFA Part B Monitoring System (December 1993 Update). 



Technical Note A 

BETOS Classification of HCPC Codes 

Revised March 4, 1994 

(1) Evaluation and Management 

MIA, Office Visits - New 

90000, 90010, 90015, 90017, 90020, 90757, 99201, 99202, 99203, 99204, 99205, 99381, 99382, 99383, 99384, 99385, 
99386, 99387, 99432 

MIB, Office Visits - Established 

90030, 90040, 90050, 90060, 90070, 90080, 90750, 90751, 90752, 90753, 90754, 90755, 90760, 90761, 90762, 90763, 
90764, 90774, 95115, 95117, 99058, 99211, 99212, 99213, 99214, 99215, 99354, 99355, 99391, 99392, 99393, 99394, 
99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99420, 99429, 99438, M0005, M0006, M0007, 
M0008 

M2A, Hospital Visit • Initial 

90200, 90215, 90220, 90225, 99218, 99219, 99220, 99221, 99222, 99223, 99431 

M2B, Hospital Visit - Subsequent 

90240, 90250, 90260, 90270, 90280, 90282, 90285, 90292, 98900, 98902, 98910, 98912, 99150, 99151, 99154, 99155, 
99156, 99217, 99231, 99232, 99233, 99238, 99356, 99357, 99361, 99362, 99433, M0021, M0022, M0023, M0029, 
M0590 

M2C, Hospital Visit - Critical Care 

94656, 94657, 94660, 94662, 99152, 99160, 99162, 99165, 99171, 99172, 99173, 99174, 99291, 99292, 99295, 99296, 
99297, 99440 

M3 , Emergency Room Visit 

90500, 90505, 90510, 90515, 90517, 90520, 90530, 90540, 90550, 90560, 90570, 90580, 90590, 99062, 99064, 99065, 
99175, 99281, 99282, 99283, 99284, 99285, 99288, M0059 

M4A, Home Visit 

90100, 90110, 90115, 90117, 90130, 90140, 90150, 90160, 90170, 99341, 99342, 99343, 99351, 99352, 99353 

M4B, Nursing Home Visit 

90300, 90315, 90320, 90340, 90350, 90360, 90370, 90400, 90410, 90415, 90420, 90430, 90440, 90450, 90460, 90470, 
99301, 99302, 99303, 99311, 99312, 99313, 99321, 99322, 99323, 99331, 99332, 99333, M0039, M0049 

MSA, Specialist - Pathology 

88104, 88105, 88106, 88107, 88108, 88109, 88110, 88111, 88112, 88113, 88114, 88115, 88116, 88117, 88118, 88119, 
88120, 88121, 88122, 88123, 88124, 88125, 88126, 88127, 88128, 88129, 88130, 88131, 88132, 88133, 88134, 88135, 
88136, 88137, 88138, 88139, 88140, 88141, 88142, 88143, 88144, 88145, 88146, 88147, 88148, 88149, 88150, 88152, 
88153, 88154, 88155, 88156, 88157, 88158, 88159, 88160, 88161, 88162, 88172, 88173, 88300, 88301, 88302, 88303, 
88304, 88305, 88306, 88307, 88308, 88309, 88321, 88322, 88323, 88324, 88325, 88326, 88327, 88328, 88329, 88330, 
88331, 88332, 88348 

MSB, Specialist - Psychiatry 

90801, 90820, 90825, 90830, 90831, 90835, 90841, 90842, 90843, 90844, 90845, 90846, 90847, 90849, 90853, 90855, 
90857, 90862, 90880, 90882, 90887, 90889, 90899, M0064, M0601 

M5C, Specialist - Opthamology 

92002, 92004, 92012, 92014, 92015, 92018, 92019, 92020, 92060, 92065, 92070, 92081, 92082, 92083, 92100, 92120, 
92130, 92140, 92225, 92226, 92230, 92235, 92250, 92260, 92283, 92284, 92285, 92286, 92287, 92310, 92311, 92312, 
92313, 92314, 92315, 92316, 92317, 92325, 92326, 92330, 92335, 92340, 92341, 92342, 92352, 92353, 92354, 92355 

Appendix 11-21 



Technical Note A (Continued) 

M5D, Specialist - Other 

57410, 59425, 59426, 59800, 59810, 86077, 86078, 86079, 90900, 90902, 90904, 90906, 90908, 90910, 90911, 90915, 
92502, 92504, 92506, 92507, 92508, 92531, 92532, 92533, 92534, 93660, 93797, 93798, 95105, 95120, 95125, 95130, 
95131, 95132, 95133, 95134, 95135, 95140, 95144, 95145, 95146, 95147, 95148, 95149, 95150, 95155, 95160, 95165, 
95170, 95180, 95831, 95832, 95833, 95834, 95851, 95852, 95857, 95880, 95881, 95882, 95883, 97700, 97701, 97720, 
97721, 97752, 99025, 99178, Q0103, Q0104, Q0109, QOllO 

M6 , Consultations 

90600, 90601, 90602, 90603, 90604, 90605, 90606, 90607, 90608, 90609, 90610, 90611, 90612, 90613, 90614, 90615, 
90616, 90617, 90618, 90619, 90620, 90621, 90622, 90623, 90624, 90625, 90626, 90627, 90628, 90629, 90630, 90631, 
90632, 90633, 90634, 90635, 90636, 90637, 90638, 90639, 90640, 90641, 90642, 90643, 90644, 90645, 90646, 90647, 
90648, 90649, 90650, 90651, 90652, 90653, 90654, 99241, 99242, 99243, 99244. 99245, 99251, 99252, 99253, 99254, 
99255, 99261, 99262, 99263, 99271, 99272, 99273, 99274, 99275 

(2) Procedures 

PO, Anesthesia 

00100, 00102, 00103, 00104, 00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148, 00160, 00162, 00164, 
00170, 00172, 00174, 00176, 00190, 00192, 00210, 00212, 00214, 00215, 00216, 00218, 00220, 00222, 00300, 00320, 
00322, 00350, 00352, 00400, 00402, 00404, 00406, 00410, 00420, 00450, 00452, 00454, 00470, 00472, 00474, 00500, 
00520, 00522, 00524, 00528, 00530, 00532, 00534, 00540, 00542, 00544, 00546, 00548, 00560, 00562, 00580, 00600, 
00604, 00620, 00622, 00630, 00632, 00634, 00670, 00700, 00702, 00730, 00740, 00750, 00752, 00754, 00756, 00770, 
00790, 00792, 00794, 00796, 00800, 00802, 00806, 00810, 00820, 00830, 00832, 00840, 00842, 00844, 00846, 00848, 
00850, 00855, 00857, 00860, 00862, 00864, 00866, 00868, 00870, 00872, 00873, 00880, 00882, 00884, 00900, 00902, 
00904, 00906, 00908, 00910, 00912, 00914, 00916, 00918, 00920, 00922, 00924. 00926, 00928, 00930, 00932, 00934, 
00936, 00938, 00940, 00942, 00944, 00946, 00948, 00950, 00952, 00955, 01000, OHIO, 01120, 01130, 01140, 01150, 
01160, 01170, 01180, 01190, 01200, 01202, 01210, 01212, 01214, 01220, 01230, 01232, 01234, 01240, 01250, 01260, 
01270, 01272, 01274, 01300, 01320, 01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404, 01420, 01430, 
01432, 01440, 01442, 01444, 01460, 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 
01502, 01520, 01522, 01600, 01610, 01620, 01622, 01630, 01632, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 
01670, 01680, 01682, 01700, 01710, 01712, 01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 
01770, 01772, 01780, 01782, 01784, 01800, 01810, 01820, 01830, 01832, 01840, 01842, 01844, 01850, 01852, 01860, 
01900, 01902, 01904, 01906, 01908, 01910, 01912, 01914, 01916, 01918, 01920, 01921, 01922, 01990, 01995, 01996, 
01999, 99100, 99116, 99135, 99140, Q0047 

PIA, Major Procedure - Breast 

19110, 19112, 19161, 19162, 19180, 19200, 19220, 19240, 19316, 19318, 19324, 19325, 19328, 19330, 19340, 19342, 
19350, 19357, 19360, 19361, 19362, 19364, 19366, 19370, 19371, 19380, 19499 

PIB, Major Procedure - Colectomy 

44140, 44141, 44143, 44144, 44145, 44146, 44147, 44150, 44151, 44152, 44153, 44155, 44156, 44160 

PIC, Major Procedure - Cholecystectomy 

47600, 47605, 47610, 47611, 47612, 47620, 47630 

PID, Major Procedure - TURP 

52601, 52606, 52612, 52614, 52620, 52630, 52640 

PIE, Major Procedure - Hysterectomy 

51925, 58150, 58152, 58180, 58200, 58205, 58210, 58260, 58262, 58263, 58265, 58267, 58270, 58275, 58280, 58285, 
59525 



Appendix 11-22 



Technical Note A (Continued) 

PIF, Major Procedure - Explor/Decompr/Excis Disc 

62295, 62296, 62297, 62299, 62301, 62302, 62303, 63001, 63003, 63005, 63010, 63011, 63015, 63016, 63017, 63020, 
63021, 63030, 63031, 63035, 63040, 63041, 63042, 63045, 63046, 63047, 63048, 63055, 63056, 63057, 63060, 63064, 
63065, 63066, 63075, 63076, 63077, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091, 63170, 63172, 
63173, 63180, 63182, 63185, 63190, 63191, 63192, 63194, 63195, 63196, 63197, 63198, 63199, 63200, 63251 

PIG, Major Procedure - Other 

11960, 11970, 11971, 15120, 15121, 15400, 15831, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15933, 
15934, 15935, 15936, 15937, 15940, 15953, 15967, 15999, 19245, 19250, 19260, 19271, 19272, 19290, 19291, 19300, 
19301, 19310, 30150, 30160, 30540, 30545, 30999, 31002, 31040, 31050, 31051, 31075, 31080, 31081, 31084, 31085, 
31086, 31087, 31090, 31225, 31230, 31299, 31300, 31320, 31360, 31365, 31367, 31368, 31370, 31375, 31380, 31382, 
31390, 31395, 31400, 31420, 31500, 31580, 31582, 31584, 31585, 31586, 31587, 31588, 31590, 31595, 31599, 31600, 
31601, 31603, 31605, 31610, 31611, 31725, 31730, 31750, 31755, 31760, 31766, 31770, 31775, 31780, 31781, 31785, 
31786, 31800, 31805, 31820, 31825, 31830, 31899, 32000, 32002, 32005, 32020, 32035, 32036, 32095, 32100, 32110, 
32120, 32124, 32140, 32141, 32150, 32151, 32160, 32200, 32215, 32220, 32225, 32310, 32315, 32320, 32400, 32402, 
32405, 32420, 32440, 32442, 32445, 32450, 32480, 32482, 32484, 32485, 32486, 32488, 32490, 32500, 32520, 32522, 
32525, 32540, 32545, 32800, 32810, 32815, 32820, 32850, 32851, 32852, 32853, 32854, 32900, 32905, 32906, 32940, 
32960, 32999, 33916, 36450, 36455, 36500, 36510, 36520, 36522, 36660, 37200, 37201, 37202, 37203, 37204, 37788, 
37790, 38100, 38101, 38102, 38115, 38230, 38240, 38241, 38380, 38381, 38382, 38525, 38562, 38564, 38720, 38721, 
38724, 38746, 38747, 38761, 38765, 38766, 38770, 38771, 38780, 38794, 38999, 39000, 39010, 39020, 39060, 39070, 
39200, 39220, 39499, 39500, 39501, 39502, 39503, 39520, 39530, 39531, 39540, 39541, 39545, 39547, 39599, 40700, 
40701, 40702, 40720, 40740, 40761, 40799, 40899, 41130, 41135, 41140, 41145, 41150, 41153, 41155, 41252, 41599, 
41870, 41872, 41874, 41899, 42145, 42150, 42200, 42205, 42210, 42215, 42220, 42225, 42226, 42227, 42235, 42260, 
42299, 42326, 42409, 42415, 42420, 42425, 42426, 42510, 42820, 42821, 42825, 42826, 42830, 42831, 42835, 42836, 
42842, 42844, 42845, 42890, 42892, 42894, 42953, 42961, 42962, 42970, 42971, 42972, 42999, 43000, 43020, 43030, 
43040, 43045, 43100, 43101, 43105, 43106, 43110, 43111, 43115, 43119, 43120, 43130, 43135, 43136, 43300, 43305, 
43310, 43312, 43320, 43321, 43324, 43325, 43330, 43331, 43340, 43341, 43350, 43351, 43352, 43400, 43401, 43410, 
43415, 43420, 43425, 43460, 43499, 43500, 43501, 43510, 43520, 43605, 43610, 43611, 43620, 43621, 43622, 43625, 
43630, 43631, 43632, 43633, 43634, 43635, 43638, 43639, 43640, 43641, 43800, 43810, 43820, 43825, 43840, 43842, 
43843, 43844, 43845, 43846, 43850, 43855, 43860, 43865, 43870, 43880, 43885, 43999, 44000, 44005, 44010, 44015, 
44020, 44021, 44025, 44040, 44050, 44055, 44060, 44110, 44111, 44115, 44120, 44125, 44130, 44131, 44300, 44305, 
44308, 44310, 44312, 44314, 44316, 44320, 44322, 44345, 44346, 44400, 44405, 44600, 44602, 44603, 44604, 44605, 
44610, 44615, 44620, 44625, 44640, 44650, 44660, 44661, 44680, 44799, 44800, 44820, 44850, 44899, 44900, 44950, 
44955, 44960, 45108, 45110, 45111, 45112, 45114, 45116, 45120, 45121, 45130, 45135, 45150, 45160, 45540, 45541, 
45550, 45800, 45805, 45820, 45825, 45999, 46281, 46700, 46705, 46715, 46716, 46730, 46735, 46740, 46742, 46744, 
46746, 46748, 46751, 46761, 46762, 46999, 47001, 47010, 47100, 47120, 47122, 47125, 47130, 47133, 47135, 47300, 
47350, 47355, 47360, 47399, 47400, 47420, 47425, 47440, 47460, 47480, 47490, 47505, 47510, 47511, 47700, 47701, 
47710, 47715, 47716, 47720, 47721, 47740, 47760, 47765, 47780, 47800, 47801, 47802, 47810, 47850, 47855, 47999, 
48000, 48001, 48005, 48020, 48100, 48102, 48120, 48140, 48145, 48146, 48148, 48150, 48151, 48152, 48153, 48154, 
48155, 48160, 48180, 48400, 48500, 48510, 48520, 48540, 48545, 48547, 48550, 48554, 48556, 48999, 49000, 49002, 
49010, 49020, 49040, 49060, 49080, 49081, 49085, 49200, 49201, 49215, 49220, 49250, 49255, 49421, 49425, 49427, 
49496, 49500, 49501, 49507, 49521, 49530, 49535, 49553, 49557, 49561, 49565, 49566, 49568, 49572, 49580, 49582, 
49585, 49587, 49600, 49605, 49606, 49610, 49611, 49630, 49635, 49640, 49900, 49905, 49999, 50010, 50045, 50060, 
50065, 50070, 50075, 50080, 50081, 50100, 50120, 50125, 50130, 50135, 50205, 50220, 50225, 50230, 50234, 50236, 
50240, 50280, 50290, 50300, 50320, 50340, 50341, 50360, 50365, 50366, 50370, 50380, 50395, 50400, 50405, 50500, 
50520, 50525, 50526, 50540, 50600, 50605, 50610, 50620, 50630, 50650, 50660, 50700, 50715, 50716, 50722, 50725, 
50727, 50728, 50740, 50750, 50760, 50770, 50780, 50781, 50782, 50783, 50785, 50786, 50800, 50801, 50810, 50815, 
50816, 50820, 50821, 50825, 50830, 50840, 50841, 50845, 50860, 50861, 50900, 50920, 50930, 50940, 51020, 51030, 
51040, 51045, 51050, 51060, 51065, 51080, 51500, 51520, 51525, 51530, 51535, 51536, 51550, 51555, 51565, 51570, 
51575, 51580, 51585, 51590, 51595, 51596, 51597, 51800, 51820, 51840, 51841, 51845, 51865, 51900, 51920, 51940, 
51960, 51980, 53025, 53210, 53215, 53415, 53443, 53445, 53505, 53899, 54000, 54111, 54112, 54125, 54130, 54135, 
54300, 54304, 54308, 54312, 54316, 54318, 54322, 54324, 54326, 54328, 54332, 54336, 54340, 54344, 54348, 54352, 

Appendix 11-23 



Technical Note A (Continued) 

54360, 54380, 54385, 54390, 54400, 54401, 54402, 54405, 54407, 54409, 54420, 54430, 54435, 54535, 54550, 54555, 
54560, 54565, 54600, 54620, 54640, 54641, 54645, 54650, 54660, 54661, 55110, 55200, 55250, 55450, 55725, 55740, 
55801, 55810, 55812, 55815, 55821, 55831, 55840, 55842, 55845, 55860, 55862, 55865, 55899, 55970, 55980, 56200, 
56620, 56625, 56630, 56631, 56632, 56633, 56634, 56635, 56636, 56637, 56640, 56641, 56680, 56685, 56700, 56710, 
56800, 56805, 56810, 57000, 57010, 57065, 57108, 57110, 57120, 57135, 57200, 57210, 57220, 57230, 57240, 57250, 
57260, 57265, 57268, 57270, 57280, 57282, 57288, 57289, 57291, 57292, 57300, 57305, 57307, 57310, 57311, 57320, 
57330, 57335, 57415, 57530, 57540, 57545, 57550, 57555, 57556, 57700, 58140, 58145, 58240, 58400, 58410, 58520, 
58540, 58600, 58605, 58611, 58615, 58700, 58720, 58740, 58750, 58752, 58760, 58770, 58800, 58805, 58820, 58822, 
58825, 58920, 58925, 58940, 58942, 58943, 58945, 58950, 58951, 58952, 58960, 58999, 59100, 59101, 59105, 59106, 
59120, 59121, 59125, 59126, 59130, 59135, 59136, 59140, 59160, 59350, 59351, 59400, 59409, 59410, 59412, 59420, 
59430, 59500, 59501, 59510, 59514, 59515, 59520, 59521, 59540, 59541, 59560, 59561, 59580, 59581, 59830, 59850, 
59851, 59852, 59899, 60220, 60225, 60240, 60242, 60245, 60246, 60252, 60254, 60260, 60261, 60270, 60281, 60500, 
60502, 60505, 60510, 60520, 60540, 60545, 60550, 60555, 60600, 60605, 60699, 61000, 61001, 61007, 61045, 61052, 
61053, 61055, 61105, 61106, 61107, 61108, 61120, 61130, 61140, 61150, 61151, 61154, 61155, 61156, 61210, 61215, 
61250, 61251, 61253, 61304, 61305, 61310, 61311, 61312, 61313, 61314, 61315, 61320, 61321, 61330, 61331, 61332, 
61333, 61334, 61340, 61341, 61343, 61345, 61440, 61450, 61458, 61460, 61470, 61480, 61490, 61491, 61500, 61501, 
61510, 61512, 61514, 61516, 61518, 61519, 61520, 61521, 61522, 61524, 61526, 61530, 61531, 61532, 61533, 61534, 
61535, 61536, 61538, 61539, 61541, 61542, 61543, 61544, 61545, 61546, 61548, 61550, 61552, 61553, 61555, 61556, 
61557, 61558, 61559, 61561, 61562, 61563, 61564, 61570, 61571, 61575, 61576, 61580, 61581, 61582, 61583, 61584, 
61585, 61590, 61591, 61592, 61595, 61596, 61597, 61598, 61600, 61601, 61605, 61606, 61607, 61608, 61609, 61610, 
61611, 61612, 61613, 61615, 61616, 61618, 61619, 61624, 61626, 61680, 61682, 61684, 61686, 61690, 61692, 61700, 
61702, 61703, 61705, 61708, 61710, 61711, 61712, 61720, 61735, 61750, 61751, 61760, 61770, 61780, 61790, 61791, 
61793, 61795, 61850, 61855, 61860, 61865, 61870, 61875, 61880, 61885, 61888, 62000, 62005, 62010, 62100, 62115, 
62116, 62117, 62120, 62121, 62140, 62141, 62142, 62143, 62145, 62146, 62147, 62180, 62190, 62192, 62194, 62200, 
62201, 62220, 62223, 62225, 62230, 62256, 62258, 62268, 62269, 62272, 62280, 62282, 62292, 62293, 62294, 63012, 
63210, 63215, 63220, 63225, 63240, 63241, 63242, 63250, 63252, 63265, 63266. 63267, 63268, 63270, 63271, 63272, 
63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63300, 63301, 63302, 
63303, 63304, 63305, 63306, 63307, 63308, 63600, 63610, 63615, 63650, 63652, 63655, 63656, 63657, 63658, 63660, 
63685, 63688, 63700, 63702, 63704, 63706, 63707, 63708, 63709, 63710, 63740, 63741, 63744, 63746, 63750, 63780, 
64746, 64752, 64755, 64760, 64761, 64762, 64763, 64764, 64766, 64768, 64771, 64792, 64804, 64806, 64809, 64811, 
64818, 64819, 64858, 64859, 64861, 64862, 64864, 64865, 64866, 64868, 64870, 64999, 66172, 69155, 69300, 69301, 
69310, 69320, 69399, 69502, 69505, 69511, 69530, 69535, 69540, 69550, 69552, 69554, 69601, 69602, 69603, 69604, 
69605, 69610, 69662, 69710, 69711, 69799, 69801, 69802, 69805, 69806, 69820, 69840, 69905, 69910, 69915, 69930, 
69950, 69955, 69960, 69965, 69970, 69979, 71036, 71037, 71090, 74327, 74350, 74351, 74355, 74356, 74360, 74361, 
74363, 74475, 74476, 74480, 74481, 74485, 74486, 75894, 75895, 75896, 75897, 75970, 75971, 75980, 75981, 75982, 
75983, 75984, 75985, 75989, 75990, 76000, 76001, 76934, 76935, 76944, 76945, 90870, 90871, 90872, 95920, 95961, 
95962, M0070, MOlOO, M0260, M0261, M0301, M0900 

P2A, Major Procedure, Cardiovascular - CABG 

33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33518, 33519, 33520, 33521, 33522, 33523, 33525, 33528, 
33530, 33533, 33534, 33535, 33536 

P2B, Major Procedure, Cardiovascular - Aneurysm Repair 

35081, 35082, 35091, 35092, 35102, 35103 

P2C, Major Procedure, Cardiovascular - Thromboendarterectomy 

35301, 35390 

P2D, Major Procedure, Cardiovascular - Coronary Angioplasty (PTCA) 

92982, 92984, 92995, 92996 



Appendix 11-24 



Technical Note A (Continued) 

P2E, Major Procedure, Cardiovascular - Pacemaker Insertion 

33200, 33201, 33205, 33206, 33207, 33208, 33210, 33211, 33212, 33213, 33214, 33216, 33217, 33218, 33219, 33220, 
33222, 33223, 33232, 33233, 33234, 33235, 33236, 33237, 33238, 33240, 33241, 33242, 33243, 33244, 33245, 33246, 
33247, 33248, 33249 

P2F, Major Procedure, Cardiovascular - Other 

33010, 33011, 33015, 33020, 33025, 33030, 33031, 33035, 33050, 33100, 33120, 33130, 33250, 33251, 33260, 33261, 
33300, 33305, 33310, 33315, 33320, 33322, 33330, 33335, 33350, 33400, 33401, 33403, 33404, 33405, 33406, 33407, 
33408, 33411, 33412, 33413, 33414, 33415, 33416, 33417, 33420, 33422, 33425, 33426, 33427, 33430, 33450, 33452, 
33460, 33463, 33464, 33465, 33468, 33470, 33471, 33472, 33474, 33475, 33476, 33478, 33480, 33481, 33482, 33483, 
33485, 33490, 33492, 33500, 33501, 33502, 33503, 33504, 33505, 33506, 33542, 33545, 33560, 33570, 33575, 33600, 
33602, 33606, 33608, 33610, 33611, 33612, 33615, 33617, 33619, 33640, 33641, 33643, 33645, 33647, 33649, 33660, 
33665, 33670, 33681, 33682, 33684, 33688, 33690, 33692, 33694, 33696, 33697, 33698, 33702, 33710, 33720, 33722, 
33730, 33732, 33735, 33736, 33737, 33738, 33739, 33750, 33755, 33762, 33764, 33766, 33767, 33770, 33771, 33774, 
33775, 33776, 33777, 33778, 33779, 33780, 33781, 33782, 33783, 33784, 33785, 33786, 33788, 33800, 33802, 33803, 
33810, 33812, 33813, 33814, 33820, 33822, 33824, 33830, 33840, 33845, 33850, 33851, 33852, 33853, 33855, 33860, 
33861, 33863, 33865, 33870, 33875, 33877, 33910, 33915, 33917, 33918, 33919, 33920, 33922, 33930, 33935, 33940, 
33945, 33960, 33961, 33970, 33971, 33972, 33973, 33974, 33975, 33976, 33977, 33978, 33999, 34001, 34051, 34101, 
34111, 34151, 34201, 34203, 34401, 34421, 34451, 34471, 34490, 34501, 34502, 34510, 34520, 34530, 35001, 35002, 
35005, 35011, 35013, 35021, 35022, 35045, 35111, 35112, 35121, 35122, 35131, 35132, 35141, 35142, 35151, 35152, 
35161, 35162, 35180, 35182, 35184, 35188, 35189, 35190, 35201, 35206, 35207, 35211, 35216, 35221, 35226, 35231, 
35236, 35241, 35246, 35251, 35256, 35261, 35266, 35271, 35276, 35281, 35286, 35311, 35321, 35331, 35341, 35351, 
35355, 35361," 35363, 35371, 35372, 35381, 35450, 35452, 35454, 35456, 35458, 35459, 35460, 35470, 35471, 35472, 
35473, 35474, 35475, 35476, 35480, 35481, 35482, 35483, 35484, 35485, 35490, 35491, 35492, 35493, 35494, 35495, 
35501, 35506, 35507, 35508, 35509, 35511, 35515, 35516, 35518, 35521, 35526, 35531, 35533, 35536, 35541, 35546, 
35548, 35549, 35551, 35556, 35558, 35560, 35563, 35565, 35566, 35571, 35582, 35583, 35585, 35587, 35601, 35606, 
35612, 35616, 35621, 35623, 35626, 35631, 35636, 35637, 35638, 35641, 35642, 35645, 35646, 35650, 35651, 35654, 
35656, 35661, 35663, 35665, 35666, 35671, 35681, 35691, 35693, 35694, 35695, 35700, 35701, 35721, 35741, 35761, 
35800, 35820, 35840, 35860, 35870, 35875, 35876, 35880, 35900, 35901, 35903, 35905, 35907, 35910, 36005, 36011, 
36012, 36013, 36014, 36015, 36216, 36217, 36218, 36246, 36247, 36248, 36260, 36261, 36262, 36299, 36460, 36480, 
36481, 36488, 36489, 36490, 36491, 36493, 36495, 36496, 36497, 36530, 36531, 36532, 36533, 36534, 36535, 36620, 
36625, 36640, 36800, 36810, 36815, 36820, 36821, 36822, 36825, 36830, 36832, 36835, 36840, 36845, 36860, 36861, 
37140, 37145, 37160, 37180, 37181, 37190, 37205, 37206, 37207, 37208, 37400, 37420, 37440, 37460, 37470, 37500, 
37520, 37540, 37560, 37565, 37600, 37605, 37606, 37607, 37615, 37616, 37617, 37618, 37620, 37650, 37651, 37660, 
37799, 75940, 75941, 75950, 75951, 75955, 75956, 75960, 75961, 75962, 75963, 75964, 75965, 75966, 75967, 75968, 
75969, 75972, 75973, 75974, 75975, 75976, 75977, 75978, 75979, 75992, 75993, 75994, 75995, 76930, 76931, 76932, 
76933, 92950, 92970, 92971, 92975, 92977, 92986, 92990, 92992, 92993, 93501, 93503, 93505, 93510, 93511, 93514, 
93515, 93524, 93526, 93527, 93528, 93529, 93535, 93536, 93561, 93562, 93570, 93600, 93602, 93603, 93604, 93605, 
93606, 93607, 93608, 93609, 93610, 93612, 93614, 93615, 93616, 93618, 93619, 93620, 93621, 93622, 93623, 93624, 
93630, 93631, 93650, 93651, 93652 

P3A, Major Procedure - Orthopedic - Hip Fracture Repair 

27232, 27234, 27235, 27236, 27240, 27242, 27244, 27245, 27248 

P3B, Major Procedure - Orthopedic - Ilip Replacement 

27125, 27126, 27127, 27130, 27131, 27132, 27134, 27135, 27137, 27138 

P3C, Major Procedure - Orthopedic - Knee Replacement 

27440, 27441, 27442, 27443, 27444, 27445, 27446, 27447 



Appendix 11-25 



Technical Note A (Continued) 

P3D, Major Procedure - Orthopedic - Other 

20661, 20693, 20802, 20804, 20805, 20806, 20808, 20812, 20816, 20820, 20822, 20823, 20824, 20826, 20827, 20828, 
20832, 20834, 20838, 20840, 20900, 20902, 20910, 20924, 20999, 21015, 21020, 21025, 21026, 21029, 21030, 21031, 
21032, 21041, 21045, 21070, 21071, 21089, 21120, 21121, 21122, 21123, 21125, 21127, 21137, 21138, 21139, 21144, 
21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21172, 21175, 21179, 21180, 21181, 21182, 21183, 
21184, 21188, 21193, 21194, 21195, 21196, 21198, 21200, 21202, 21203, 21204, 21206, 21207, 21208, 21209, 21210, 
21215, 21230, 21235, 21239, 21240, 21242, 21243, 21244, 21245, 21246, 21247, 21248, 21249, 21250, 21254, 21255, 
21256, 21260, 21261, 21263, 21267, 21268, 21270, 21275, 21280, 21282, 21295, 21296, 21299, 21336, 21339, 21343, 
21344, 21345, 21346, 21347, 21348, 21356, 21366, 21385, 21386, 21387, 21390, 21395, 21400, 21401, 21406, 21407, 
21408, 21421, 21422, 21423, 21431, 21432, 21433, 21435, 21436, 21440, 21445, 21454, 21455, 21461, 21462, 21465, 
21470, 21493, 21499, 21557, 21615, 21616, 21620, 21627, 21630, 21632, 21633, 21700, 21705, 21720, 21725, 21740, 
21741, 21805, 21810, 21820, 21825, 21899, 21935, 22100, 22101, 22102, 22105, 22106, 22107, 22110, 22111, 22112, 
22113, 22114, 22115, 22120, 22121, 22122, 22128, 22129, 22130, 22140, 22141, 22142, 22145, 22148, 22150, 22151, 
22152, 22200, 22201, 22202, 22203, 22206, 22207, 22210, 22212, 22214, 22220, 22222, 22224, 22230, 22250, 22251, 
22305, 22310, 22315, 22325, 22326, 22327, 22330, 22335, 22345, 22355, 22356, 22360, 22361, 22370, 22371, 22379, 
22548, 22550, 22552, 22554, 22555, 22556, 22558, 22560, 22561, 22565, 22585, 22590, 22595, 22600, 22605, 22610, 
22612, 22615, 22617, 22620, 22625, 22630, 22640, 22645, 22650, 22655, 22670, 22680, 22700, 22720, 22730, 22735, 
22800, 22801, 22802, 22803, 22810, 22812, 22820, 22830, 22840, 22842, 22845, 22849, 22850, 22852, 22855, 22899, 
22910, 22999, 23036, 23077, 23105, 23106, 23107, 23110, 23120, 23125, 23145, 23146, 23155, 23156, 23190, 23195, 
23200, 23210, 23220, 23221, 23222, 23332, 23395, 23397, 23400, 23410, 23412, 23415, 23420, 23430, 23440, 23450, 
23455, 23460, 23462, 23465, 23466, 23470, 23472, 23480, 23485, 23490, 23491, 23530, 23532, 23550, 23552, 23580, 
23585, 23615, 23616, 23680, 23800, 23802, 23900, 23920, 23921, 23931, 24006, 24077, 24102, 24150, 24151, 24152, 
' 24153, 24305, 24360, 24361, 24362, 24363, 24365, 24366, 24400, 24410, 24430, 24435, 24495, 24498, 24515, 24516, 
24545, 24546, 24566, 24575, 24579, 24582, 24587, 24588, 24635, 24660, 24800, 24802, 24900, 24920, 24925, 24930, 
24931, 24935, 24940, 24999, 25031, 25077, 25105, 25115, 25116, 25118, 25119, 25170, 25250, 25251, 25330, 25331, 
25332, 25335, 25350, 25355, 25360, 25365, 25370, 25375, 25400, 25405, 25415, 25420, 25425, 25426, 25440, 25441, 
25442, 25443, 25444, 25445, 25446, 25447, 25449, 25490, 25491, 25492, 25520, 25525, 25526, 25574, 25676, 25800, 
25805, 25810, 25815, 25820, 25825, 25900, 25905, 25907, 25909, 25915, 25920, 25922, 25924, 25927, 25929, 25931, 
25999, 26037, 26117, 26121, 26123, 26125, 26130, 26260, 26357, 26415, 26416, 26437, 26478, 26479, 26499, 26504, 
26527, 26548, 26550, 26560, 26561, 26562, 26565, 26580, 26585, 26587, 26590, 26591, 26593, 26596, 26597, 26608, 
26615, 26850, 26852, 26992, 27001, 27005, 27006, 27010, 27015, 27025, 27026, 27030, 27033, 27049, 27050, 27052, 
27054, 27060, 27062, 27066, 27067, 27070, 27071, 27075, 27076, 27077, 27078, 27079, 27090, 27091, 27097, 27098, 
27100, 27105, 27110, 27111, 27115, 27120, 27122, 27140, 27146, 27147, 27151, 27156, 27157, 27158, 27161, 27165, 
27170, 27177, 27178, 27179, 27181, 27185, 27187, 27192, 27193, 27194, 27212, 27214, 27215, 27216, 27217, 27218, 
27220, 27222, 27224, 27225, 27226, 27227, 27228, 27253, 27254, 27255, 27258, 27259, 27265, 27266, 27280, 27281, 
27282, 27284, 27286, 27290, 27295, 27299, 27311, 27329, 27331, 27332, 27333, 27334, 27335, 27350, 27356, 27357, 
27358, 27365, 27380, 27381, 27385, 27386, 27394, 27395, 27403, 27405, 27407, 27409, 27410, 27411, 27413, 27418, 
27420, 27422, 27424, 27427, 27428, 27429, 27430, 27435, 27437, 27438, 27448, 27449, 27450, 27452, 27454, 27455, 
27457, 27460, 27462, 27465, 27466, 27468, 27470, 27472, 27475, 27477, 27479, 27485, 27486, 27487, 27488, 27495, 
27496, 27497, 27498, 27499, 27501, 27502, 27503, 27504, 27506, 27507, 27509, 27510, 27511, 27512, 27513, 27514, 
27517, 27518, 27519, 27524, 27535, 27536, 27537, 27540, 27554, 27556, 27557, 27558, 27566, 27580, 27590, 27591, 
27592, 27594, 27596, 27598, 27599, 27600, 27601, 27602, 27604, 27615, 27625, 27626, 27645, 27646, 27647, 27687, 
27695, 27696, 27698, 27700, 27702, 27703, 27704, 27705, 27707, 27709, 27712, 27715, 27720, 27722, 27724, 27725, 
27727, 27730, 27732, 27734, 27740, 27742, 27745, 27750, 27752, 27754, 27756, 27758, 27759, 27762, 27788, 27806, 
27810, 27812, 27814, 27818, 27820, 27822, 27823, 27824, 27825, 27826, 27827, 27828, 27829, 27832, 27870, 27871, 
27880, 27881, 27882, 27884, 27886, 27888, 27889, 27892, 27893, 27894, 27899, 28001, 28020, 28022, 28024, 28046, 
28052, 28054, 28070, 28100, 28104, 28106, 28108, 28109, 28116, 28119, 28123, 28124, 28126, 28130, 28153, 28236, 
28238, 28262, 28288, 28299, 28300, 28302, 28304, 28305, 28307, 28309, 28313, 28340, 28341, 28344, 28345, 28360, 
28410, 28415, 28440, 28445, 28460, 28480, 28531, 28550, 28576, 28580, 28610, 28636, 28640, 28666, 28675, 28705, 
28715, 28725, 28730, 28735, 28737, 28740, 28800, 28805, 28810, 28899 



Appendix 11-26 



Technical Note A (Continued) 

P4A, Eye Procedures - Corneal transplant 

65710, 65720, 65725, 65730, 65740, 65745, 65750, 65755, 65760, 65765, 65767, 65770 

P4B, Eye Procedures - Cataract Rem/Lens Ins 

66830, 66840, 66850, 66852, 66915, 66920, 66930, 66940, 66945, 66983, 66984, 66985, 66986 

P4C, Eye Procedures - Retinal Detachment 

67101, 67103, 67104, 67105, 67106, 67107, 67108, 67109, 67110, 67112, 67120, 67141, 67142, 67143, 67144, 67145 

P4D, Eye Procedures - Treatment of Retinal Lesions 

67208, 67210, 67212, 67213, 67214, 67216, 67218, 67222, 67223, 67224, 67227, 67228 

P4E, Eye - Other 

65091, 65093, 65101, 65103, 65105, 65110, 65112, 65114, 65125, 65130, 65135, 65140, 65150, 65155, 65175, 65230, 
65235, 65245, 65260, 65265, 65270, 65272, 65273, 65275, 65280, 65285, 65290, 65300, 65400, 65410, 65420, 65426, 
65771, 65772, 65775, 65800, 65805, 65810, 65815, 65850, 65855, 65860, 65865, 65870, 65875, 65880, 65900, 65920, 
65930, 66020, 66030, 66130, 66150, 66155, 66160, 66165, 66170, 66180, 66185, 66220, 66225, 66250, 66500, 66505, 
66600, 66605, 66625, 66630, 66635, 66680, 66682, 66700, 66701, 66702, 66710, 66720, 66721, 66740, 66741, 66761, 
66762, 66770, 66800, 66801, 66802, 66820, 66821, 66825, 66980, 66999, 67005, 67010, 67015, 67025, 67028, 67030, 
67031, 67035, 67036, 67038, 67039, 67040, 67102, 67115, 67121, 67146, 67226, 67250, 67255, 67299, 67311, 67312, 
67313, 67314, 67316, 67318, 67320, 67331, 67332, 67334, 67335, 67340, 67343, 67345, 67350, 67399, 67400, 67405, 
67412, 67413, 67414, 67415, 67420, 67430, 67440, 67445, 67450, 67500, 67505, 67515, 67550, 67560, 67570, 67599, 
67715, 67801, 67805, 67808, 67830, 67835, 67880, 67882, 67900, 67901, 67902, 67903, 67904, 67906, 67907, 67908, 
67909, 67911, 67914, 67916, 67917, 67921, 67923, 67924, 67930, 67935, 67950, 67961, 67966, 67971, 67973, 67974, 
67975, 67999, 68130, 68320, 68325, 68326, 68328, 68330, 68335, 68340, 68360, 68362, 68399, 68500, 68505, 68510, 
68520, 68540, 68550, 68700, 68720, 68745, 68750, 68761, 68830, 68899 

P5A, Ambulatory Procedures - Skin 

10141, 11042, 11043, 11044, 11200, 11201, 11401, 11402, 11403, 11404, 11406, 11421, 11422, 11423, 11424, 11426, 
11441, 11442, 11443, 11444, 11446, 11471, 11600, 11601, 11602, 11603, 11604, 11606, 11620, 11621, 11622, 11623, 
11624, 11626, 11640, 11641, 11642, 11643, 11644, 11646, 11750, 11755, 11770, 11771, 11772, 12006, 12007, 12017, 
12018, 12036, 12037, 12046, 12047, 12056, 12057, 13101, 13121, 13132, 13152, 13300, 14001, 14020, 14021, 14041, 
14060, 14061, 14300, 14350, 15000, 15050, 15100, 15101, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 
15350, 15410, 15412, 15414, 15416, 15500, 15505, 15510, 15515, 15540, 15545, 15550, 15555, 15570, 15572, 15574, 
15576, 15580, 15600, 15610, 15620, 15625, 15630, 15650, 15700, 15710, 15720, 15730, 15732, 15734, 15736, 15738, 
15740, 15745, 15750, 15755, 15760, 15770, 15840, 15841, 15842, 15845, 15850, 15851, 15876, 15877, 15878, 15879, 
15920, 15922, 15931, 15941, 15942, 15943, 15944, 15945, 15946, 15950, 15951, 15952, 15954, 15955, 15956, 15958, 
15960, 15961, 15964, 15965, 15966, 15970, 15971, 15972, 15973, 15974, 15975, 15980, 15981, 15982, 15983, 16010, 
16015, 17106, 17107, 17108, 17260, 17261, 17262, 17263, 17264, 17266, 17270. 17271, 17272, 17273, 17274, 17276, 
17280, 17281, 17282, 17283, 17284, 17286, 96910, 96912, 96913 

P5B, Ambulatory Procedures - Musculoskeletal 

20005, 20205, 20225, 20240, 20245, 20250, 20251, 20525, 20650, 20660, 20662, 20663, 20665, 20680, 20694, 20912, 
20920, 20922, 20926, 20955, 20960, 20962, 20969, 20970, 20971, 20972, 20973, 20975, 21010, 21011, 21034, 21040, 
21044, 21050, 21051, 21060, 21061, 21100, 21310, 21315, 21320, 21325, 21330, 21335, 21338, 21340, 21355, 21360, 
21365, 21450, 21451, 21452, 21453, 21480, 21485, 21490, 21494, 21495, 21501, 21502, 21510, 21511, 21555, 21556, 
21600, 21610, 21750, 22505, 22900, 23000, 23020, 23030, 23035, 23040, 23042, 23044, 23066, 23076, 23100, 23101, 
23130, 23140, 23150, 23170, 23171, 23172, 23173, 23174, 23175, 23180, 23181, 23182, 23183, 23184, 23185, 23331, 
23405, 23406, 23505, 23515, 23605, 23610, 23625, 23630, 23655, 23658, 23660, 23665, 23670, 23675, 23700, 23930, 
23935, 23936, 24000, 24001, 24075, 24076, 24100, 24101, 24105, 24110, 24115, 24116, 24120, 24125, 24126, 24130, 
24134, 24135, 24136, 24137, 24138, 24139, 24140, 24144, 24145, 24146, 24147, 24148, 24155, 24160, 24164, 24201, 
24301, 24310, 24320, 24330, 24331, 24340, 24342, 24350, 24351, 24352, 24354, 24356, 24420, 24470, 24505, 24506, 

Appendix 11-27 



Technical Note A (Continued) 

24510, 24530, 24531, 24535, 24536, 24538, 24540, 24542, 24565, 24570, 24577, 24578, 24580, 24581, 24583, 24585, 
24586, 24605, 24610, 24615, 24620, 24625, 24655, 24665, 24666, 24675, 24680, 24685, 24700, 25000, 25005, 25020, 
25023, 25028, 25035, 25036, 25040, 25041, 25066, 25076, 25085, 25100, 25101, 25107, 25110, 25111, 25112, 25120, 
25125, 25126, 25130, 25135, 25136, 25145, 25146, 25150, 25151, 25153, 25210, 25215, 25230, 25240, 25248, 25260, 
25263, 25265, 25270, 25272, 25274, 25280, 25290, 25295, 25300, 25301, 25310, 25312, 25315, 25316, 25317, 25318, 
25320, 25390, 25391, 25392, 25393, 25450, 25455, 25505, 25510, 25515, 25535, 25540, 25545, 25565, 25570, 25575, 
25605, 25610, 25611, 25615, 25620, 25626, 25628, 25635, 25640, 25645, 25660, 25665, 25670, 25675, 25680, 25685, 
25690, 25695, 25700, 26011, 26020, 26025, 26030, 26032, 26034, 26035, 26040, 26045, 26055, 26060, 26070, 26075, 
26080, 26100, 26105, 26110, 26115, 26116, 26120, 26122, 26124, 26126, 26128, 26135, 26140, 26145, 26160, 26170, 
26180, 26200, 26205, 26206, 26210, 26215, 26216, 26230, 26235, 26250, 26255, 26261, 26350, 26352, 26356, 26358, 
26370, 26372, 26373, 26390, 26392, 26410, 26412, 26418, 26420, 26426, 26428, 26432, 26433, 26434, 26440, 26442, 
26445, 26449, 26450, 26455, 26460, 26471, 26474, 26476, 26477, 26480, 26483, 26485, 26489, 26490, 26492, 26494, 
26496, 26497, 26498, 26500, 26502, 26508, 26510, 26516, 26517, 26518, 26520, 26525, 26530, 26531, 26535, 26536, 
26540, 26541, 26542, 26545, 26552, 26555, 26557, 26558, 26559, 26567, 26568, 26570, 26574, 26605, 26607, 26610, 
26645, 26650, 26655, 26660, 26665, 26675, 26676, 26680, 26685, 26686, 26705, 26706, 26710, 26715, 26727, 26730, 
26735, 26744, 26746, 26765, 26775, 26780, 26785, 26820, 26841, 26842, 26843, 26844, 26860, 26861, 26862, 26863, 
26910, 26951, 26952, 26990, 26991, 26995, 27000, 27002, 27003, 27004, 27031, 27035, 27040, 27041, 27047, 27048, 
27065, 27080, 27087, 27088, 27196, 27201, 27202, 27252, 27257, 27275, 27301, 27303, 27304, 27305, 27306, 27307, 
27310, 27315, 27320, 27324, 27327, 27328, 27330, 27345, 27355, 27360, 27361, 27372, 27390, 27391, 27392, 27393, 
27396, 27397, 27400, 27425, 27522, 27532, 27534, 27552, 27562, 27564, 27570, 27603, 27605, 27606, 27607, 27608, 
27610, 27611, 27612, 27620, 27630, 27635, 27637, 27638, 27640, 27641, 27650, 27652, 27654, 27656, 27658, 27659, 
27664, 27665, 27675, 27676, 27680, 27681, 27685, 27686, 27690, 27691, 27692, 27764, 27766, 27781, 27782, 27784, 
" 27790, 27792," 27802, 27804, 27831, 27842, 27844, 27846, 27848, 27860, 28002, 28003, 28004, 28005, 28006, 28008, 
28010, 28011, 28030, 28035, 28045, 28050, 28062, 28072, 28080, 28086, 28088, 28090, 28092, 28102, 28103, 28107, 
28110, 28111, 28112, 28113, 28114, 28118, 28120, 28121, 28122, 28135, 28140, 28171, 28173, 28175, 28193, 28200, 
28202, 28208, 28210, 28222, 28225, 28226, 28230, 28232, 28234, 28240, 28250, 28260, 28261, 28264, 28270, 28272, 
28285, 28286, 28290, 28292, 28293, 28294, 28296, 28297, 28298, 28306, 28308, 28310, 28312, 28315, 28320, 28322, 
28405, 28406, 28420, 28435, 28436, 28465, 28485, 28500, 28505, 28520, 28525, 28545, 28546, 28555, 28575, 28585, 
28605, 28606, 28615, 28635, 28645, 28665, 28670, 28750, 28755, 28760, 28820, 28825 

P5C, Ambulatory Procedures - Inguinal Hernia Repair 

49495, 49505, 49506, 49510, 49515, 49520, 49525, 49550, 49552, 49555 

PSD, Ambulatory Procedures - Lithotripsy 

50590 

P5E, Ambulatory Procedures - Other 

19020, 19101, 19120, 19121, 19125, 19126, 19140, 19160, 19182, 19355, 30115, 30116, 30117, 30118, 30125, 30130, 
30140, 30310, 30320, 30400, 30410, 30420, 30430, 30435, 30450, 30500, 30520, 30580, 30600, 30620, 30630, 30915, 
30920, 31020, 31021, 31030, 31031, 31032, 31033, 31070, 31200, 31201, 31205, 31612, 31613, 31614, 31700, 31717, 
31719, 31720, 37609, 37700, 37701, 37720, 37721, 37730, 37731, 37735, 37737, 37760, 37780, 37781, 37785, 37787, 
38305, 38308, 38500, 38510, 38520, 38530, 38540, 38542, 38550, 38555, 38700, 38701, 38740, 38745, 38760, 40500, 
40510, 40520, 40525, 40527, 40530, 40650, 40654, 40801, 40805, 40814, 40816, 40818, 40831, 40840, 40842, 40843, 
40844, 40845, 41000, 41005, 41100, 41105, 41114, 41115, 41116, 41120, 41251, 41806, 41826, 41827, 42000, 42104, 
42106, 42107, 42120, 42140, 42182, 42305, 42320, 42325, 42335, 42340, 42408, 42410, 42440, 42450, 42500, 42505, 
42507, 42508, 42509, 42600, 42665, 42699, 42720, 42725, 42806, 42808, 42810, 42815, 42860, 42870, 42880, 42900, 
42950, 42955, 43246, 43326, 43450, 43451, 43453, 43455, 43456, 43458, 43750, 43830, 43831, 43832, 44340, 45000, 
45005, 45020, 45170, 45180, 45181, 45500, 45505, 45521, 45560, 45900, 45905, 45910, 45915, 46000, 46032, 46040, 
46045, 46060, 46080, 46200, 46211, 46250, 46255, 46257, 46258, 46260, 46261, 46262, 46270, 46275, 46280, 46285, 
46530, 46750, 46753, 46754, 46760, 46924, 46937, 46938, 47000, 49400, 49401, 49420, 49426, 49501, 49540, 49560, 
49570, 49575, 49581, 49590, 50020, 50040, 50200, 50390, 50392, 50393, 50396, 50398, 50974, 50976, 50978, 50980, 
51005, 51010, 51710, 52500, 52650, 52700, 53000, 53010, 53020, 53021, 53040, 53220, 53230, 53235, 53240, 53265, 

Appendix 11-28 



Technical Note A (Continued) 

53275, 53400, 53405, 53410, 53420, 53425, 53430, 53440, 53447, 53449, 53450, 53460, 53502, 53510, 53515, 53520, 
53600, 53601, 53605, 53620, 53621, 53660, 53661, 53665, 54001, 54015, 54110, 54115, 54120, 54152, 54154, 54161, 
54205, 54220, 54440, 54505, 54506, 54510, 54520, 54521, 54530, 54670, 54680, 54700, 54820, 54830, 54840, 54860, 
54861, 54900, 54901, 55040, 55041, 55060, 55120, 55150, 55175, 55180, 55400, 55401, 55500, 55520, 55530, 55535, 
55540, 55605, 55650, 55651, 55680, 55705, 55720, 56000, 56405, 56440, 56515, 56605, 56606, 56740, 57020, 57105, 
57130, 57400, 57520, 57720, 57820, 58120, 58320, 58321, 58322, 58323, 58345, 58350, 58900, 58970, 58974, 58976, 
59320, 59325, 59801, 59811, 59812, 59820, 59821, 59840, 59841, 59870, 60200, 60280, 61020, 61026, 61050, 61070, 
62270, 62273, 62274, 62275, 62276, 62277, 62278, 62279, 62281, 62287, 62288, 62289, 62298, 64408, 64410, 64415, 
64417, 64420, 64421, 64430, 64442, 64443, 64510, 64520, 64530, 64600, 64605, 64610, 64622, 64623, 64630, 64702, 
64704, 64708, 64712, 64713, 64714, 64716, 64718, 64719, 64721, 64722, 64726, 64727, 64732, 64734, 64736, 64738, 
64740, 64742, 64744, 64772, 64774, 64776, 64778, 64782, 64783, 64784, 64786, 64787, 64788, 64790, 64795, 64802, 
64803, 64830, 64831, 64832, 64834, 64835, 64836, 64837, 64840, 64856, 64857, 64872, 64874, 64876, 64885, 64886, 
64890, 64891, 64892, 64893, 64895, 64896, 64897, 64898, 64901, 64902, 64905, 64907, 69105, 69110, 69120, 69140, 
69145, 69150, 69205, 69420, 69421, 69436, 69437, 69440, 69450, 69501, 69620, 69631, 69632, 69633, 69635, 69636, 
69637, 69641, 69642, 69643, 69644, 69645, 69646, 69650, 69660, 69661, 69666, 69667, 69670, 69676, 69677, 69700, 
69720, 69725, 69740, 69745, 74283, 76003, 76095, 76938, 76939, 76942, 76943. 76946, 76947, 76948, 76949, 77610, 
77615, 79000, 79001, 79020, 79030, 79100, 79300, 79400, 79420, 79440, 88000, 88005, 88007, 88012, 88014, 88016, 
88020, 88025, 88027, 88028, 88029, 88036, 88037, 88040, 88045, 88171, 92960, 99180, 99182, 99183 

P6A, Minor Procedures - Skin 

10000, 10001, 10002, 10003, 10020, 10040, 10060, 10061, 10080, 10081, 10100, 10101, 10120, 10121, 10140, 10160, 
10180, 11000, 11001, 11040, 11041, 11050, 11051, 11052, 11060, 11061, 11062, 11100, 11101, 11300, 11301, 11302, 
11303, 11305, 11306, 11307, 11308, 11310, 11311, 11312, 11313, 11400, 11420, 11440, 11450, 11451, 11462, 11463, 
11470, 11700, 11701, 11710, 11711, 11730, 11731, 11732, 11740, 11752, 11760, 11762, 11765, 11900, 11901, 11920, 
11921, 11922, 11950, 11951, 11952, 11954, 11975, 11976, 11977, 12001, 12002, 12004, 12005, 12011, 12013, 12014, 
12015, 12016, 12020, 12021, 12031, 12032, 12034, 12035, 12041, 12042, 12044, 12045, 12051, 12052, 12053, 12054, 
12055, 13100, 13120, 13131, 13150, 13151, 13160, 14000, 14040, 15775, 15776, 15780, 15781, 15782, 15783, 15786, 
15787, 15788, 15789, 15790, 15791, 15792, 15793, 15810, 15811, 15819, 15820, 15821, 15822, 15823, 15824, 15825, 
15826, 15828, 15829, 15852, 15860, 15875, 16000, 16020, 16025, 16030, 16035, 16040, 16041, 16042, 17000, 17001, 
17002, 17010, 17100, 17101, 17102, 17104, 17105, 17110, 17200, 17201, 17250, 17300, 17301, 17303, 17304, 17305, 
17306, 17307, 17310, 17340, 17360, 17380, 17999, 36468, 36469, 96999 

P6B, Minor Procedures-Musculoskeletai 

20000, 20010, 20200, 20206, 20220, 20500, 20520, 20550, 20600, 20605, 20610, 20615, 20670, 20690, 20691, 20692, 
20950, 20974, 20976, 21079, 21080, 21081, 21082, 21083, 21084, 21085, 21086, 21087, 21088, 21110, 21300, 21337, 
21497, 21550, 21800, 21920, 21925, 21930, 22010, 22011, 22012, 22030, 22031, 22032, 22033, 23031, 23065, 23075, 
23330, 23500, 23510, 23520, 23525, 23540, 23545, 23570, 23575, 23600, 23620, 23650, 24065, 24066, 24200, 24500, 
24560, 24576, 24600, 24640, 24650, 24670, 25065, 25075, 25500, 25530, 25560, 25600, 25622, 25624, 25630, 25650, 
26010, 26236, 26262, 26320, 26600, 26641, 26670, 26700, 26720, 26725, 26740, 26742, 26743, 26750, 26755, 26756, 
26760, 26770, 26776, 27086, 27175, 27176, 27190, 27191, 27195, 27200, 27210, 27211, 27230, 27238, 27246, 27250, 
27256, 27323, 27340, 27500, 27508, 27516, 27520, 27530, 27538, 27550, 27560, 27613, 27614, 27618, 27619, 27760, 
27780, 27786, 27800, 27808, 27816, 27830, 27840, 28043, 28060, 28150, 28160, 28190, 28192, 28220, 28280, 28400, 
28430, 28450, 28455, 28456, 28470, 28475, 28476, 28490, 28495, 28496, 28510, 28515, 28530, 28540, 28570, 28600, 
28630, 28660, 29000, 29010, 29015, 29020, 29025, 29035, 29040, 29044, 29046, 29049, 29055, 29058, 29065, 29075, 
29085, 29105, 29125, 29126, 29130, 29131, 29200, 29220, 29240, 29260, 29280, 29305, 29325, 29345, 29355, 29358, 
29365, 29405, 29425, 29435, 29440, 29450, 29455, 29505, 29515, 29520, 29530, 29540, 29550, 29580, 29590, 29700, 
29705, 29710, 29715, 29720, 29730, 29740, 29750, 29751, 29799, 36680 

P6C, Minor Procedures, Other (MFS) 

19000, 19001, 19030, 19100, 19396, 30000, 30020, 30100, 30110, 30120, 30124, 30200, 30210, 30220, 30300, 30460, 
30462, 30560, 30801, 30802, 30901, 30903, 30905, 30906, 30930, 31000, 31502, 36400, 36405, 36406, 36410, 36420, 
36425, 36430, 36431, 36440, 36470, 36471, 36485, 36494, 36600, 38300, 38505, 40490, 40652, 40800, 40804, 40806, 

Appendix 11-29 



Technical Noie A (Continued) 

40808, 40810, 40812, 40819, 40820, 40830, 41006, 41007, 41008, 41009, 41010, 41015, 41016, 41017, 41018, 41108, 
41110, 41112, 41113, 41250, 41500, 41510, 41520, 41800, 41805, 41825, 42100, 42160, 42180, 42280, 42281, 42300, 
42310, 42330, 42400, 42405, 42650, 42660, 42700, 42800, 42802, 42804, 42809, 42960, 43600, 43760, 43761, 43765, 
44100, 44500, 45100, 45105, 45520, 46030, 46050, 46070, 46083, 46210, 46220, 46221, 46230, 46320, 46500, 46510, 
46900, 46910, 46916, 46917, 46922, 46930, 46934, 46935, 46936, 46940, 46942, 46945, 46946, 47525, 47530, 49180, 
50686, 50688, 51000, 51700, 51705, 51725, 51726, 51727, 51728, 51729, 51730, 51732, 51736, 51739, 51741, 51772, 
51774, 51785, 51786, 51788, 51792, 51795, 51797, 51860, 51880, 52450, 52510, 53060, 53080, 53085, 53200, 53250, 
53260, 53270, 53442, 53640, 53670, 53675, 54050, 54055, 54056, 54057, 54060, 54065, 54100, 54105, 54150, 54160, 
54200, 54231, 54235, 54250, 54450, 54500, 54800, 55000, 55100, 55600, 55601, 55700, 55870, 56100, 56400, 56420, 
56441, 56500, 56501, 56505, 56506, 56507, 56510, 56600, 56720, 57050, 57057, 57060, 57061, 57063, 57100, 57150, 
57160, 57170, 57180, 57500, 57505, 57510, 57511, 57513, 57600, 57620, 57800, 58100, 58102, 58103, 58300, 58301, 
58310, 58311, 58972, 59000, 59010, 59011, 59012, 59015, 59020, 59025, 59030, 59031, 59050, 59200, 59300, 59305, 
59414, 60000, 60100, 64400, 64402, 64405, 64412, 64413, 64418, 64425, 64435, 64440, 64441, 64445, 64450, 64505, 
64508, 64550, 64553, 64555, 64560, 64565, 64573, 64575, 64577, 64580, 64585, 64590, 64595, 64612, 64613, 64620, 
64640, 64680, 65205, 65210, 65220, 65222, 65240, 65286, 65430, 65435, 65436, 65450, 65600, 65820, 65830, 67700, 
67710, 67800, 67810, 67820, 67825, 67840, 67850, 67875, 67915, 67922, 67938, 68020, 68040, 68100, 68110, 68115, 
68135, 68200, 68400, 68420, 68440, 68525, 68530, 68705, 68760, 68770, 68800, 68820, 68825, 68840, 69000, 69005, 
69020, 69100, 69200, 69210, 69220, 69222, 69223, 69400, 69401, 69405, 69410, 69424, 69425, 69433, 74235, 76970, 
85095, 85096, 85097, 85100, 85101, 85102, 85103, 85105, 85109, 86342, 88170, 89100, 89105, 89350, 90749, 90780, 
90781, 90782, 90783, 90784, 90788, 90798, 90799, 91000, 91055, 91060, 91100, 91105, 92275, 92358, 92371, 92538, 
92953, 94640, 94642, 94650, 94651, 94652, 94664, 94665, 94667, 94668, 95829, 95830, 95860, 95861, 95863, 95864, 
95867, 95868, 95869, 95872, 95875, 95953, 95954, 95955, 95956. 95958, 96900, 97010, 97012, 97014, 97016, 97018, 
97020, 97022, 97024, 97026, 97028, 97039, 97050, 97110, 97112, 97114, 97116, 97118, 97120, 97122, 97124, 97126, 
97128, 97139, 97145, 97200, 97201, 97220, 97221, 97240, 97241, 97250, 97260, 97261, 97500, 97501, 97520, 97521, 
97530, 97531, 97540, 97541, 97740, 97741, 97799, 98925, 98926, 98927, 98928, 98929, 99185, 99186, 99190, 99191, 
99192, 99195, G0002, MOlOl, M0702, M0704, M0706, M0708, M0710, M0722, M0724, M0726, M0728, M0730, 
M0994, Q0091 

P6D, Minor Procedures, Other (non MFS) 

30111, 30800, 30805, 30820, 30902, 30904, 31001, 41820, 41821, 41822, 41823, 41828, 41830, 41850, 58101, 65825, 
69090, 69221, 69434, 69611, 85060, 85667, 86128, 86130, 86404, 90700, 90701, 90702, 90703, 90704, 90705, 90706, 
90707, 90708, 90709, 90710, 90711, 90712, 90713, 90714, 90716, 90717, 90718, 90719, 90720, 90725, 90726, 90727, 
90728, 90730, 90731, 90732, 90733, 90735, 90737, 90741, 90742, 92370, 99170, M0910 

P7A, Oncology - Radiation Therapy 

76950, 76960, 77261, 77262, 77263, 77280, 77285, 77290, 77295, 77299, 77300, 77305, 77310, 77315, 77321, 77326, 
77327, 77328, 77331, 77332, 77333, 77334, 77336, 77370, 77399, 77400, 77401, 77402, 77403, 77404, 77405, 77406, 
77407, 77408, 77409, 77410, 77411, 77412, 77413, 77414, 77415, 77416, 77417, 77419, 77420, 77425, 77430, 77431, 
77432, 77465, 77470, 77499, 77750, 77761, 77762, 77763, 77776, 77777, 77778, 77781, 77782, 77783, 77784, 77789, 
77790, 77799, 79035, 79200, 79900 

P7B, Oncology - Other 

51720, 77600, 77605, 77620, 90790, 90791, 96400, 96405, 96406, 96408, 96410, 96412, 96414, 96420, 96422, 96423, 
96425, 96440, 96445, 96450, 96500, 96501, 96504, 96505, 96508, 96509, 96510, 96511, 96512, 96520, 96524, 96526, 
96530, 96535, 96538, 96540, M0024, M0072, M0080 

PSA, Endoscopy - Arthroscopy 

29800, 29804, 29815, 29819, 29820, 29821, 29822, 29823, 29825, 29826, 29830, 29834, 29835, 29836, 29837, 29838, 
29840, 29843, 29844, 29845, 29846, 29847, 29848, 29850, 29851, 29855, 29856, 29870, 29871, 29872, 29874, 29875, 
29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29890, 29894, 29895, 
29896, 29897, 29898 



Appendix 11-30 



Technical Note A (Continued) 

P8B, Endoscopy - Upper G.I. 

43200, 43202, 43204, 43205, 43215, 43216, 43217, 43219, 43220, 43225, 43226, 43227, 43228, 43234, 43235, 43239, 
43241, 43243, 43244, 43245, 43247, 43248, 43250, 43251, 43255, 43258, 43259, 43260, 43261, 43262, 43263, 43264, 
43265, 43267, 43268, 43269, 43271, 43272, 76975 

P8C, Endoscopy - Sigmoidoscopy 

45300, 45302, 45303, 45305, 45307, 45308, 45309, 45310, 45315, 45317, 45319, 45320, 45321, 45330, 45331, 45332, 
45333, 45334, 45336, 45337, 45338, 45339 

PSD, Endoscopy - Colonoscopy 

44388, 44389, 44390, 44391, 44392, 44393, 44394, 45355, 45360, 45365, 45367, 45368, 45369, 45370, 45371, 45372, 
45378, 45379, 45380, 45382, 45383, 45384, 45385 

P8E, Endoscopy - Cystoscopy 

52000, 52005, 52007, 52010, 52100, 52105, 52107, 52202, 52204, 52212, 52214, 52222, 52224, 52232, 52234, 52235, 
52240, 52250, 52260, 52265, 52270, 52275, 52276, 52277, 52280, 52281, 52282, 52283, 52285, 52290, 52300, 52305, 
52310, 52315, 52317, 52318, 52320, 52325, 52330, 52332, 52334, 52335, 52336, 52337, 52338, 52339, 52340 

P8F, Endoscopy - Bronchoscopy 

31615, 31620, 31621, 31622, 31625, 31626, 31627, 31628, 31629, 31630, 31631, 31635, 31640, 31641, 31645, 31646, 
31650, 31651, 31659 

P8G, Endoscopy - Laparoscopic Cholecystectomy 

49310, 49311, 49315, 56324, 56340, 56341, 56342 

P8H, Endoscopy, Laryngoscopy 

31505, 31510, 31511, 31512, 31513, 31515, 31520, 31525, 31526, 31527, 31528, 31529, 31530, 31531, 31535, 31536, 
31540, 31541, 31560, 31561, 31570, 31571, 31575, 31576, 31577, 31578, 31579 

P8I, Endoscopy, Other 

23356, 27373, 27374, 27376, 27377, 27378, 27379, 27436, 27851, 27853, 31071, 31231, 31233, 31235, 31237, 31238, 
31239, 31240, 31245, 31246, 31247, 31248, 31249, 31250, 31251, 31252, 31254, 31255, 31256, 31258, 31260, 31261, 
31262, 31263, 31264, 31265, 31266, 31267, 31268, 31269, 31270, 31271, 31275, 31277, 31280, 31281, 31282, 31283, 
31284, 31285, 31286, 31287, 31288, 31290, 31291, 31292, 31293, 31294, 32601, 32602, 32603, 32604, 32605, 32606, 
32650, 32651, 32652, 32653, 32654, 32655, 32656, 32657, 32658, 32659, 32660, 32661, 32662, 32663, 32664, 32665, 
32700, 32705, 39400, 43834, 44360, 44361, 44363, 44364, 44365, 44366, 44369, 44372, 44373, 44376, 44377, 44378, 
44380, 44382, 44385, 44386, 45386, 46600, 46602, 46604, 46606, 46608, 46610, 46611, 46612, 46614, 46615, 47550, 
47552, 47553, 47554, 47555, 47556, 49300, 49301, 49302, 49303, 50550, 50551, 50552, 50553, 50555, 50557, 50559, 
50560, 50561, 50570, 50572, 50574, 50575, 50576, 50578, 50580, 50951, 50952, 50953, 50955, 50957, 50959, 50960, 
50961, 50970, 50972, 51715, 52605, 52800, 52805, 56300, 56301, 56302, 56303, 56304, 56305, 56306, 56307, 56308, 
56309, 56311, 56312, 56313, 56315, 56316, 56317, 56320, 56322, 56323, 56350, 56351, 56352, 56353, 56354, 56355, 
56356, 56360, 56361, 56362, 56363, 56399, 57450, 57451, 57452, 57454, 57460, 58980, 58982, 58983, 58984, 58985, 
58986, 58987, 58988, 58990, 58992, 58994, 58995, 58996, 59150, 59151, 74328, 74329, 74330, 74340, 92511 

P9A, Dialysis Services (MFS) 

90935, 90937, 90945, 90947, 90997, 90999 

P9B, Dialysis Services (non MFS) 

90918, 90919, 90920, 90921, 90922, 90940, 90941, 90942, 90943, 90944, 90946, 90948, 90949, 90950, 90951, 90952, 
90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, 90962, 90963, 90964, 90965, 90966, 90967, 90968, 
90969, 90970, 90971, 90972, 90973, 90974, 90975, 90976, 90977, 90978, 90979, 90980, 90981, 90982, 90983, 90984, 



Appendix 11-31 



Technical Note A (Continued) 

90985, 90986, 90987, 90988, 90989, 90990, 90991, 90992, 90993, 90994, 90995, 90996, 90998, M0916, M0920, 
M0928, M0931, M0932, M0936, M0937, M0945, M0974, M0978, M0982 

(3) Imaging 

IIA, Standard Imaging - Chest 

71010, 71015, 71020, 71021, 71022, 71023, 71030, 71034, 71035 

IIB, Standard Imaging - Musculoskeletal 

70100, 70110, 70120, 70130, 70140, 70150, 70160, 70250, 70260, 71100, 71101, 71110, 71111, 71120, 71130, 72010, 
72020, 72040, 72050, 72052, 72069, 72070, 72072, 72074, 72080, 72090, 72100, 72110, 72114, 72120, 72170, 72180, 
72190, 72200, 72202, 72220, 73000, 73010, 73020, 73030, 73040, 73041, 73050, 73060, 73070, 73080, 73085, 73086, 
73090, 73092, 73100, 73110, 73115, 73116, 73120, 73130, 73140, 73500, 73510, 73520, 73525, 73526, 73530, 73531, 
73540, 73550, 73560, 73562, 73564, 73565, 73570, 73580, 73581, 73590, 73592, 73600, 73610, 73615, 73616, 73620, 
73630, 76020, 76040, 76061, 76062, 76065, 76066, 76075 

lie, Standard Imaging - Breast 

76086, 76087, 76088, 76089, 76090, 76091, 76092, 76096, 76097, 76098 

UD, Standard Imaging - Contrast G.I. 

74190, 74210, 74220, 74230, 74240, 74241, 74245, 74246, 74247, 74249, 74250, 74251, 74260, 74270, 74280, 76010 

HE, Standard Imaging - Nuclear Medicine 

78000, 78001, 78003, 78006, 78007, 78010, 78011, 78015, 78016, 78017, 78018, 78070, 78075, 78099, 78102, 78103, 
78104, 78110, 78111, 78120, 78121, 78122, 78130, 78135, 78140, 78160, 78162, 78170, 78172, 78185, 78186, 78190, 
78191, 78192, 78193, 78195, 78199, 78201, 78202, 78205, 78215, 78216, 78220, 78223, 78225, 78230, 78231, 78232, 
78258, 78261, 78262, 78264, 78270, 78271, 78272, 78276, 78278, 78280, 78282, 78290, 78291, 78299, 78300, 78305, 
78306, 78310, 78315, 78320, 78350, 78351, 78380, 78381, 78399, 78401, 78402, 78403, 78404, 78407, 78411, 78412, 
78414, 78415, 78418, 78419, 78420, 78422, 78424, 78425, 78428, 78435, 78445, 78455, 78457, 78458, 78460, 78461, 
78462, 78463, 78464, 78465, 78466, 78467, 78468, 78469, 78470, 78471, 78472, 78473, 78474, 78475, 78476, 78477, 
78478, 78479, 78480, 78481, 78483, 78484, 78485, 78486, 78487, 78489, 78499, 78580, 78581, 78582, 78584, 78585, 
78586, 78587, 78591, 78593, 78594, 78596, 78599, 78600, 78601, 78605, 78606, 78607, 78608, 78609, 78610, 78615, 
78630, 78635, 78640, 78645, 78650, 78652, 78655, 78660, 78699, 78700, 78701, 78704, 78707, 78710, 78715, 78720, 
78725, 78726, 78727, 78730, 78740, 78760, 78761, 78799, 78800, 78801, 78802, 78803, 78805, 78806, 78807, 78890, 
78891, 78895, 78990, 78999, 79999 

IIF, Standard Imaging - Other 

20501, 21116, 23350, 24220, 25246, 27093, 27095, 27370, 27648, 31708, 36000, 36001, 38790, 38791, 42550, 50394, 
50684, 50690, 51600, 51605, 51610, 54230, 55300, 58340, 68850, 70030, 70040, 70050, 70134, 70170, 70171, 70190, 
70200, 70210, 70220, 70230, 70231, 70240, 70300, 70310, 70320, 70328, 70330, 70332, 70333, 70350, 70355, 70360, 
70370, 70371, 70373, 70374, 70380, 70390, 70391, 71000, 71038, 71040, 71041, 71060, 71061, 73650, 73660, 74000, 
74010, 74020, 74022, 74285, 74290, 74291, 74300, 74301, 74305, 74310, 74315, 74400, 74405, 74410, 74415, 74420, 
74425, 74426, 74430, 74431, 74440, 74441, 74445, 74446, 74450. 74451, 74455, 74456, 74710, 74720, 74725, 74730, 
74731, 74740, 74741, 74742, 74770, 74771, 74775, 75809, 76080, 76081, 76100, 76101, 76102, 76120, 76125, 76130, 
76135, 76137, 76140, 76150, 76350, 76499, 93280, R0070, R0071, R0072, R0073, R0074, R0075, R0076 

I2A, Advanced Imaging - CAT: Head 

70450, 70460, 70470, 70480, 70481, 70482 



Appendix 11-32 



Technical Note A (Continued) 

I2B, Advanced Imaging ■ CAT: Other 

70486, 70487, 70488, 70490, 70491, 70492, 71250, 71260, 71270, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 
72132, 72133, 72192, 72193, 72194, 73200, 73201, 73202, 73700, 73701, 73702, 74150, 74160, 74170, 76070, 76355, 
76360, 76361, 76365, 76366, 76370, 76375, 76380, R0065 

I2C, Advanced Imaging - MRI: Brain 

70541, 70550, 70551, 70552, 70553 

I2D, Advanced Imaging - MRI: Other 

70336, 70540, 71550, 71555, 72140, 72141, 72142, 72143, 72144, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 
72159, 72196, 72198, 73220, 73221, 73225, 73720, 73721, 73725, 74181, 74185, 75552, 75553, 75554, 75555, 75556, 
76400 

I3A, Echography - Eye 

76511, 76512, 76513, 76515, 76516, 76517, 76519, 76529, 76530 

I3B, Echography - Abdomen/Pelvis 

76700, 76705, 76770, 76775, 76778, 76805, 76810, 76815, 76816, 76818, 76825, 76826, 76827, 76828, 76830, 76855, 
76856, 76857 

I3C, Echography - Heart 

76620, 76625, 76627, 76628, 76629, 76632, 93300, 93305, 93307, 93308, 93309, 93312, 93313, 93314, 93320, 93321, 
93325 

I3D, Echography - Carotid Arteries 

93870, 93880, 93882 

I3E, Echography - Prostate, Transrectal 

76872 

I3F, Echography - Other 

76500, 76505, 76506, 76535, 76536, 76550, 76601, 76604, 76640, 76645, 76800, 76870, 76880, 76925, 76926, 76986, 
76990, 76991, 76999, 93925, 93926, 93930, 93931, 93970, 93971, 93975, 93976, 93978, 93979, 93980, 93981 

I4A, Imaging/Procedure - Heartjnc Cardiac Cath 

75500, 75501, 75505, 75506, 75507, 75509, 75519, 75520, 75523, 75524, 75527, 75528, 75750, 75751, 75752, 75753, 
75754, 75755, 75756, 75757, 75762, 75764, 75766, 75767, 93539, 93540, 93541, 93542, 93543, 93544, 93545, 93546, 
93547, 93548, 93549, 93550, 93551, 93552, 93553, 93555, 93556 

I4B, Imaging/Procedure - Other 

31656, 31710, 31715, 36010, 36100, 36101, 36120, 36140, 36145, 36160, 36200, 36210, 36215, 36220, 36230, 36240, 
36245, 36250, 38200, 47500, 62284, 62290, 62291, 70010, 7001 1, 70015, 70016, 70020, 72240, 72241, 72255, 72256, 
72265, 72266, 72270, 72271, 72285, 72286, 72295, 72296, 74320, 74321, 74470, 74471, 75600, 75601, 75605, 75606, 
75620, 75621, 75622, 75623, 75625, 75626, 75627, 75628, 75630, 75631, 75650, 75651, 75652, 75653, 75654, 75655, 
75656, 75657, 75658, 75659, 75660, 75661, 75662, 75663, 75665, 75667, 75669, 75671, 75672, 75673, 75676, 75677, 
75678, 75680, 75681, 75682, 75685, 75686, 75687, 75690, 75691, 75692, 75695, 75696, 75697, 75705, 75706, 75710, 
75711, 75712, 75716, 75717, 75718, 75722, 75723, 75724, 75725, 75726, 75727, 75728, 75731, 75732, 75733, 75734, 
75736, 75737, 75738, 75741, 75742, 75743, 75744, 75746, 75747, 75748, 75772, 75773, 75774, 75775, 75790, 75801, 
75802, 75803, 75804, 75805, 75806, 75807, 75808, 75810, 75811, 75820, 75821, 75822, 75823, 75825, 75826, 75827, 
75828, 75831, 75832, 75833, 75834, 75840, 75841, 75842, 75843, 75845, 75846, 75847, 75850, 75851, 75860, 75861, 
75870, 75871, 75872, 75873, 75880, 75881, 75885, 75886, 75887, 75888, 75889, 75890, 75891, 75892, 75893, 75898, 
78221, 78240, 78409, 78413 

Appendix 11-33 



Technical Note A (Continued) 

(4) Tests 

TIA, Lab Tests - Routine Venipuncture (not MFS) 

36415, GOOOl 

TIB, Lab Tests - Automated General Profiles 

80002, 80003, 80004, 80005, 80006, 80007, 80008, 80009, 80010, 80011, 80012, 80016, 80018, 80019, 80050, 80052, 
80053 

TIC, Lab Tests - Urinalysis 

81000, 81002, 81003, 81004, 81005, 81006, 81007, 81010, 81011, 81012, 81015, 81020, 81025, 81030, 81050, 81099 

TID, Lab Tests - Blood Counts 

85005, 85007, 85008, 85009, 85012, 85013, 85014, 85018, 85021, 85022, 85023, 85024, 85025, 85027, 85028, 85029, 
85030, 85031, 85041, 85044, 85045, 85048, Q0116 

TIE, Lab Tests - Glucose 

82947, 82948, 82949, 82950, 82951, 82952, 82953, 82962 

TIF, Lab Tests - Bacterial Cultures 

87040, 87045, 87060, 87070, 87072, 87075, 87076, 87081, 87082, 87083, 87084, 87085, 87086, 87087, 87088 

TIG, Lab Test, Other (MFS) 

80500, 80502, 83020(mod=26), 83912(mod=26), 84165(mod=26), 84190(mod=26), 85390(mod=26), 
85576(mod=26), 86255(mod=26), 86256(mod=26), 86320(mod=26), 86325(mod=26), 86327(mod=26), 
86334(mod=26), 86490, 86510, 86540, 86580, 86585, 87164(mod=26), 87207(mod=26), 88151(mod=26), 88180, 
88182, 88199, 88299, 88311, 88312, 88313, 88314, 88318, 88319, 88342, 88346, 88347, 88355, 88356, 88358, 88362, 
88365, 88399, 89060(mod=26), 89360, 89399, 94710, 99000, 99001, P3001(mod=26), Q0092, Q0092 

TIH, Lab Test, Other (non MFS) 

53800, 80031, 80032, 80033, 80034, 80040, 80042, 80055, 80056, 80057, 80058, 80059, 80060, 80061, 80062, 80063, 
80064, 80065, 80066, 80067, 80068, 80070, 80071, 80072, 80073, 80075, 80080, 80082, 80084, 80085, 80086, 80088, 
80089, 80090, 80091, 80092, 80099, 80100, 80101, 80102, 80103, 80150, 80152, 80154, 80156, 80158, 80160, 80162, 
80164, 80166, 80168, 80170, 80172, 80174, 80176, 80178, 80182, 80184, 80185, 80186, 80188, 80190, 80192, 80194, 
80196, 80198, 80200, 80202, 80299, 80400, 80402, 80406, 80408, 80410, 80412, 80414, 80415, 80418, 80420, 80422, 
80424, 80426, 80428, 80430, 80432, 80434, 80435, 80436, 80438, 80439, 80440, 82000, 82003, 82005, 82009, 82010, 
82011, 82012, 82013, 82015, 82024, 82030, 82035, 82040, 82042, 82043, 82044, 82055, 82060, 82065, 82070, 82072, 
82075, 82076, 82078, 82085, 82086, 82087, 82088, 82089, 82091, 82095, 82096, 82100, 82101, 82103, 82104, 82105, 
82106, 82108, 82112, 82115, 82126, 82128, 82130, 82131, 82134, 82135, 82137, 82138, 82140, 82141, 82142, 82143, 
82145, 82150, 82154, 82155, 82156, 82157, 82159, 82160, 82163, 82164, 82165, 82168, 82170, 82172, 82173, 82175, 
82180, 82190, 82205, 82210, 82225, 82230, 82231, 82232, 82235, 82236, 82239, 82240, 82245, 82250, 82251, 82252, 
82260, 82265, 82268, 82270, 82273, 82280, 82285, 82286, 82290, 82291, 82300, 82305, 82306, 82307, 82308, 82310, 
82315, 82320, 82325, 82330, 82331, 82335, 82340, 82345, 82355, 82360, 82365, 82370, 82372, 82374, 82375, 82376, 
82378, 82380, 82382, 82383, 82384, 82387, 82390, 82397, 82400, 82405, 82415, 82418, 82420, 82425, 8242Z, 
82435, 82436, 82437, 82438, 82441, 82443, 82465, 82470, 82480, 82482, 82484, 82485, 82486, 82487, 82488, 82489, 
82490, 82491, 82495, 82505, 82507, 82512, 82520, 82525, 82526, 82528, 82529, 82530, 82531, 82532, 82533, 82534, 
82536, 82537, 82538, 82539, 82540, 82545, 82546, 82550, 82552, 82553, 82554, 82555, 82565, 82570, 82575, 82585, 
82595, 82600, 82601, 82606, 82607, 82608, 82614, 82615, 82620, 82624, 82626, 82627, 82628, 82633, 82634, 82635, 
82636, 82638, 82639, 82640, 82641, 82643, 82646, 82649, 82651, 82652, 82654, 82656, 82660, 82662, 82664, 82666, 
82668, 82670, 82671, 82672, 82673, 82674, 82676, 82677, 82678, 82679, 82690, 82691, 82692, 82693, 82694, 82696, 
82705, 82710, 82715, 82720, 82725, 82727, 82728, 82730, 82735, 82740, 82741, 82742, 82745, 82746, 82747, 82750, 
82755, 82756, 82757, 82759, 82760, 82763, 82765, 82775, 82776, 82780, 82784, 82785, 82786, 82787, 82790, 82791, 

Appendix 11-34 



Technical Note A (Continued) 

82792, 82793, 82795, 82800, 82801, 82802, 82803, 82804, 82805, 82810, 82812, 82817, 82820, 82926, 82927, 82928, 
82929, 82931, 82932, 82938, 82941, 82942, 82943, 82944, 82946, 82954, 82955, 82960, 82961, 82963, 82965, 82975, 
82977, 82978, 82979, 82980, 82985, 82995, 82996, 82997, 82998, 83000, 83001, 83002, 83003, 83004, 83005, 83008, 
83010, 83011, 83012, 83015, 83018, 83020(mod NE 26), 83026, 83030, 83033, 83036, 83040, 83045, 83050, 83051, 
83052, 83053, 83055, 83060, 83065, 83068, 83069, 83070, 83071, 83086, 83087, 83088, 83093, 83094, 83095, 83150, 
83485, 83486, 83491, 83492, 83493, 83494, 83495, 83496, 83497, 83498, 83499, 83500, 83505, 83510, 83518, 83519, 
83520, 83523, 83524, 83525, 83526, 83527, 83528, 83530, 83540, 83545, 83546, 83550, 83555, 83565, 83570, 83571, 
83576, 83578, 83582, 83583, 83584, 83586, 83587, 83588, 83589, 83590, 83593, 83597, 83599, 83600, 83605, 83610, 
83615, 83620, 83624, 83625, 83626, 83628, 83629, 83631, 83632, 83633, 83634, 83645, 83650, 83655, 83660, 83661, 
83662, 83670, 83675, 83680, 83681, 83685, 83690, 83700, 83705, 83715, 83717, 83718, 83719, 83720, 83721, 83725, 
83727, 83728, 83730, 83735, 83740, 83750, 83755, 83760, 83765, 83775, 83785, 83790, 83795, 83799, 83805, 83825, 
83830, 83835, 83840, 83842, 83845, 83857, 83858, 83859, 83860, 83861, 83862, 83864, 83865, 83866, 83872, 83873, 
83874, 83875, 83880, 83883, 83885, 83887, 83890, 83892, 83894, 83895, 83896, 83898, 83900, 83910, 83912(mod 
NE 26), 83913, 83915, 83916, 83917, 83918, 83920, 83925, 83930, 83935, 83937, 83938, 83945, 83946, 83947, 
83948, 83949, 83965, 83970, 83971, 83972, 83973, 83974, 83975, 83985, 83986, 83992, 83995, 84005, 84021, 84022, 
84030, 84031, 84033, 84035, 84037, 84038, 84039, 84040, 84045, 84060, 84061, 84065, 84066, 84075, 84078, 84080, 
84081, 84082, 84083, 84085, 84087, 84090, 84100, 84105, 84106, 84110, 84118, 84119, 84120, 84121, 84126, 84127, 
84128, 84132, 84133, 84134, 84135, 84136, 84138, 84139, 84140, 84141, 84142, 84143, 84144, 84146, 84147, 84149, 
84150, 84153, 84155, 84160, 84165(mod NE 26), 84170, 84175, 84176, 84180, 84181, 84182, 84185, 84190(mod 
NE 26), 84195, 84200, 84201, 84202, 84203, 84205, 84206, 84207, 84208, 84210, 84220, 84228, 84230, 84231, 
84232, 84233, 84234, 84235, 84236, 84238, 84244, 84246, 84252, 84255, 84260, 84270, 84275, 84285, 84295, 84300, 
84305, 84307, 84310, 84311, 84315, 84317, 84318, 84324, 84375, 84392, 84395, 84401, 84402, 84403, 84405, 84406, 
84407, 84408, 84409, 84410, 84420, 84425, 84430, 84432, 84434, 84435, 84436, 84437, 84439, 84442, 84443, 84444, 
84445, 84446, 84447, 84448, 84449, 84450, 84455, 84460, 84465, 84466, 84472, 84474, 84476, 84478, 84479, 84480, 
84481, 84482, 84483, 84485, 84488, 84490, 84510, 84520, 84525, 84540, 84545, 84550, 84555, 84560, 84565, 84570, 
84575, 84577, 84578, 84580, 84583, 84584, 84585, 84586, 84588, 84589, 84590, 84595, 84597, 84600, 84605, 84610, 
84613, 84615, 84620, 84630, 84635, 84645, 84681, 84695, 84701, 84702, 84703, 84800, 84810, 84830, 84999, 85000, 
85002, 85130, 85150, 85160, 85165, 85170, 85171, 85172, 85175, 85210, 85220, 85230, 85240, 85242, 85244, 85245, 
85246, 85247, 85250, 85260, 85270, 85280, 85290, 85291, 85292, 85293, 85300, 85301, 85302, 85303, 85305, 85306, 
85310, 85311, 85320, 85330, 85335, 85337, 85340, 85341, 85345, 85347, 85348, 85360, 85362, 85363, 85364, 85365, 
85366, 85367, 85368, 85369, 85370, 85371, 85372, 85376, 85377, 85378, 85379, 85384, 85385, 85390(mod NE 26), 
85392, 85395, 85396, 85398, 85400, 85410, 85415, 85420, 85421, 85426, 85441, 85445, 85460, 85475, 85520, 
85525, 85530, 85535, 85538, 85540, 85544, 85547, 85548, 85549, 85555, 85556, 85557, 85560, 85575, 85576(mod 
NE 26), 85577, 85580, 85585, 85590, 85595, 85597, 85610, 85611, 85612, 85613, 85614, 85615, 85618, 85630, 
85632, 85635, 85650, 85651, 85660, 85665, 85670, 85675, 85700, 85705, 85710, 85711, 85720, 85730, 85732, 85810, 
85820, 85999, 86000, 86002, 86003, 86004, 86005, 86006, 86007, 86008, 86009, 86011, 86012, 86013, 86014, 86016, 
86017, 86018, 86019, 86021, 86022, 86023, 86024, 86026, 86028, 86031, 86032, 86033, 86034, 86035, 86038, 86039, 
86045, 86060, 86063, 86064, 86066, 86067, 86068, 86069, 86070, 86072, 86073, 86074, 86075, 86076, 86080, 86082, 
86083, 86084, 86085, 86090, 86095, 86096, 86100, 86105, 86115, 86120, 86140, 86147, 86149, 86151, 86155, 86156, 
86157, 86158, 86159, 86160, 86161, 86162, 86163, 86164, 86171, 86185, 86209, 86215, 86225, 86226, 86227, 86228, 
86229, 86235, 86243, 86244, 86255(mod NE 26), 86256(niod NE 26), 86265, 86266, 86267, 86277, 86280, 86281, 
86282, 86283, 86285, 86286, 86287, 86288, 86289, 86290, 86291, 86293, 86295, 86296, 86298, 86299, 86300, 86302, 
86305, 86306, 86308, 86309, 86310, 86311, 86312, 86314, 86316, 86317, 86318, 86319, 86320(mod NE 26), 
86325(mod NE 26), 86327(mod NE 26), 86329, 86331, 86332, 86333, 86334(mod NE 26), 86335, 86337, 86338, 
86340, 86341, 86343, 86344, 86349, 86353, 86357, 86358, 86359, 86360, 86376, 86377, 86378, 86382, 86384, 86385, 
86386, 86402, 86403, 86405, 86410, 86411, 86412, 86415, 86417, 86418, 86419, 86420, 86421, 86422, 86423, 86425, 
86430, 86431, 86455, 86485, 86565, 86586, 86587, 86588, 86590, 86592, 86593, 86594, 86595, 86600, 86602, 86603, 
86606, 86609, 86612, 86615, 86618, 86619, 86622, 86625, 86628, 86630, 86631, 86632, 86635, 86638, 86641, 86644, 
86645, 86648, 86650, 86651, 86652, 86653, 86654, 86658, 86660, 86662, 86663, 86664, 86665, 86668, 86671, 86674, 
86677, 86681, 86682, 86684, 86685, 86687, 86688, 86689, 86692, 86694, 86695, 86698, 86701, 86702, 86703, 86710, 
86713, 86717, 86720, 86723, 86727, 86729, 86732, 86735, 86738, 86741, 86744, 86747, 86750, 86753, 86756, 86759, 
86762, 86765, 86768, 86771, 86774, 86777, 86778, 86781, 86784, 86787, 86790, 86793, 86800, 86805, 86806, 86807, 

Appendix 11-35 



Technical Note A (Continued) 

86808, 86810, 86812, 86813, 86816, 86817, 86821, 86822, 86849, 86850, 86860, 86870, 86880, 86885, 86885, 86886, 
86890, 86891, 86900, 86901, 86903, 86904, 86905, 86906, 86910, 86911, 86915, 86920, 86921, 86922, 86927, 86930, 
86931, 86932, 86940, 86941, 86945, 86950, 86965, 86970, 86971, 86972, 86975, 86976, 86977, 86978, 86985, 86999, 
87001, 87003, 87015, 87101, 87102, 87103, 87106, 87109, 87110, 87116, 87117, 87118, 87140, 87143, 87145, 87147, 
87151, 87155, 87158, 87163, 87164(mod NE 26), 87166, 87173, 87174, 87175, 87176, 87177, 87178, 87179, 87181, 
87184, 87186, 87187, 87188, 87190, 87192, 87197, 87205, 87206, 87207(mod NE 26), 87208, 87210, 87211, 87220, 
87230, 87250, 87252, 87253, 87999, 88099, 88151(mod NE 26), 88156, 88174, 88230, 88233, 88235, 88237, 88239, 
88245, 88248, 88250, 88260, 88261, 88262, 88263, 88265, 88267, 88268, 88269, 88270, 88280, 88283, 88285, 88289, 
88316, 88317, 88345, 88370, 88371, 88372, 89005, 89050, 89051, 89060(mod NE 26), 89070, 89125, 89160, 89180, 
89190, 89205, 89300, 89310, 89320, 89323, 89325, 89329, 89330, 89355, 89365, P2026, P2027, P2028, P2029, 
P2031, P2032, P2033, P2038, P3000, P3001(mod NE 26), P7001, P7020, P9605, P9610, P9615, Q0095, Q0097, 
Q0098, Q0099, QOlOO, QOlOl, Q0102, QOlll, Q0112, Q0113, Q0114, Q0115 

T2A, Other Tests - Electrocardiograms 

93000, 93005, 93010, 93012, 93014, 93040, 93041, 93042, 93045 

T2B, Other Tests - Cardiovascular Stress Tests 

93015, 93016, 93017, 93018, 93350 

T2C, Other Tests - EKG Monitoring 

93224, 93225, 93226, 93227, 93230, 93231, 93232, 93233, 93235, 93236, 93237, 93258, 93259, 93262, 93263, 93266, 
93268, 93269, 93270, 93271, 93272, 93273, 93274, 93275, 93276, 93277, 93278, Q0019, Q0020, Q0021, Q0022, 
Q0023, Q0024, Q0025, Q0026, Q0027. Q0028, O0029, Q0030, Q0031, Q0032 

T2D, Other Tests - Other 

54240, 63690, 63691, 74275, 76900, 76910, 88349, 89130, 89132, 89135, 89136, 89140, 89141, 90778, 91010, 91011, 
91012, 91020, 91030, 91032, 91033, 91052, 91065, 91090, 91122, 91299, 92265, 92270, 92280, 92499, 92512, 92516, 
92520, 92541, 92542, 92543, 92544, 92545, 92546, 92547, 92551, 92552, 92553, 92555, 92556, 92557, 92559, 92560, 
92561, 92562, 92563, 92564, 92565, 92566, 92567, 92568, 92569, 92571, 92572, 92573, 92574, 92575, 92576, 92577, 
92578, 92580, 92581, 92582, 92583, 92584, 92585, 92589, 92590, 92591, 92592, 92593, 92594, 92595, 92596, 92599, 
93024, 93201, 93202, 93204, 93205, 93208, 93209, 93210, 93220, 93221, 93222, 93240, 93255, 93640, 93641, 93642, 
93700, 93720, 93721, 93722, 93724, 93725, 93728, 93731, 93732, 93733, 93734, 93735, 93736, 93737, 93738, 93740, 
93760, 93762, 93770, 93780, 93781, 93784, 93786, 93788, 93790, 93791, 93792, 93793, 93794, 93795, 93796, 93799, 
93850, 93860, 93875, 93886, 93888, 93890, 93910, 93920, 93921, 93922, 93923, 93924, 93950, 93960, 93965, 94010, 
94060, 94070, 94150, 94160, 94200, 94240, 94250, 94260, 94350, 94360, 94370, 94375, 94400, 94450, 94620, 94680, 
94681, 94690, 94700, 94705, 94715, 94720, 94725, 94750, 94760, 94761, 94762, 94770, 94772, 94799, 95000, 95001, 
95002, 95003, 95004, 95005, 95006, 95007, 95010, 95011, 95014, 95015, 95016, 95017, 95018, 95020, 95021, 95022, 
95023, 95024, 95027, 95028, 95030, 95031, 95032, 95033, 95034, 95040, 95041, 95042, 95043, 95044, 95050, 95051, 
95052, 95056, 95060, 95065, 95070, 95071, 95075, 95077, 95078, 95080, 95081, 95082, 95199, 95805, 95807, 95808, 
95810, 95816, 95817, 95819, 95821, 95822, 95823, 95824, 95826, 95827, 95828, 95842, 95858, 95900, 95904, 95925, 
95933, 95935, 95937, 95950, 95951, 95952, 95999, M0520, M0525, M0526, M0530, M0535, M0540, M0560, 
M0575, M0580, M0585, M0592, Q0035 

(5) Durable Medical Equipment 

DIA, Med/Surg Supplies 

A4190, A4200, A4202, A4203, A4204, A4205, A4206, A4207, A4208, A4209, A4210, A4211, A4212, A4213, 
A4214, A4215, A4216, A4220, A4244, A4245, A4246, A4247, A4250, A4253, A4256, A4259, A4260, A4262, 
A4263, A4265, A4270, A4300, A4305, A4306, A4310, A4311, A4312, A4313, A4314, A4315, A4316, A4320, 
A4322, A4323, A4326, A4327, A4328, A4329, A4330, A4335, A4338, A4340, A4344, A4346, A4347, A4351, 
A4352, A4354, A4355, A4356, A4357, A4358, A4359, A4361, A4362, A4363, A4364, A4367, A4397, A4398, 
A4399, A4400, A4402, A4404, A4421, A4454, A4455, A4460, A4465, A4470, A4480, A4490, A4495, A4500, 

Appendix 11-36 



Technical Note A (Continued) 

A4510, A4550, A4554, A4555, A4556, A4557, A4558, A4560, A4565, A4570, A4572, A4580, A4581, A4590, 
A4610, A4611, A4612, A4613, A4615, A4616, A4617, A4618, A4619, A4620, A4621, A4622, A4623, A4624, 
A4625, A4626, A4627, A4630, A4631, A4635, A4636, A4637, A4640, A4641, A4644, A4645, A4646, A4647, 
A4648, A4649, A4650, A4655, A4660, A4663, A4670, A4680, A4690, A4700, A4705, A4712, A4714, A4730, 
A4735, A4740, A4750, A4755, A4760, A4765, A4770, A4771, A4772, A4773, A4774, A4780, A4790, A4800, 
A4820, A4850, A4860, A4870, A4880, A4890, A4900, A4901, A4905, A4910, A4912, A4913, A4914, A4918, 
A4919, A4920, A4921, A4927, A5051, A5052, A5053, A5054, A5055, A5061, A5062, A5063, A5064, A5065, 
A5071, A5072, A5073, A5074, A5075, A5081, A5082, A5093, A5102, A5105, A5112, A5113, A5114, A5119, 
A5121, A5122, A5123, A5126, A5131, A5149, A9150, A9160, A9170, A9180, A9190, A9250, A9260, A9270, 
A9280, A9290, A9300, K0131, K0132, K0133, K0134, K0135, K0136, K0137, K0138, K0139, K0148, K0149, 
K0150, K0151, K0152, K0153, K0154, K0164, K0165, Q0105, Q0106, Q0107 

DIB, Hospital Beds 

EOlOO, E0105, EOllO, EOlll, E0112, E0113, E0114, E0116, E0130, E0135, E0141, E0142, E0143, E0145, E0146, 
E0147, E0153, E0154, E0155, E0156, E0157, E0158, E0160, E0161, E0162, E0163, E0164, E0165, E0166, E0167, 
E0175, E0176, E0177, E0178, E0179, E0180, E0181, E0182, E0184, E0185, E0186, E0187, E0188, E0189, E0191, 
E0192, E0193, E0194, E0196, E0197, E0198, E0199, E0200, E0202, E0205, E0210, E0215, E0220, E0225, E0230, 
E0235, E0236, E0237, E0238, E0239, E0241, E0242, E0243, E0244, E0245, E0246, E0249, E0250, E0251, E0255, 
E0256, E0260, E0261, E0265, E0266, E0270, E0271, E0272, E0273, E0274, E0275, E0276, E0277, E0280, E0290, 
E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0305, E0310, E0315, E0325, E0326, E0500, E0505, EOSIO, 
E0515, E0550, E0555, E0560, E0565, E0570, E0575, E0580, E0585, E0600, E0601, E0605, E0606, E0607, E0608, 
E0609, E0610, E0615, E0620, E0621, E0625, E0627, E0628, E0629, E0630, E0635, E0650, E0651, E0652, E0655, 
E0660, E0665, E0666, E0667, E0668, E0690, E0700, E0710, E0720, E0730, E0731, E0744, E0745, E0746, E0747, 
E0749, E0750, E0840, E0850, E0860, E0870, E0880, E0890, E0900, E0910, E0920, E0930, E0935, E0940, E0941, 
E0942, E0943, E0944, E0945, E0946, E0947, E0948, E1300, E1310, E1350, E1510, E1520, E1530, E1540, E1550, 
E1560, E1570, E1575, E1580, E1590, E1592, E1594, E1600, E1610, E1615, E1620, E1625, E1630, E1632, E1635, 
E1636, E1640, E1699, E1700, E1701, E1702, LOlOO, LOllO, L0120, L0130, L0140, L0150, L0160, L0170, L0172, 
L0174, L0180, L0190, L0200, L0210, L0220, L0300, L0310, L0315, L0317, L0320, L0330, L0340, L0350, L0360, 
L0370, L0380, L0390, L0400, L0410, L0420, L0430, L0440, L{)500, LOS 10, LOS 15, L0520, L0S30, L0540, L0550, 
L0S60, L056S, L0600, L0610, L0620, L0700, L0710, L0810, L0820, L0830, L0860, L0900, L0910, L0920, L0930, 
L0940, L0950, L0960, L0970, L0972, L0974, L0976, L0978, L0980, L0982, LIOOO, LlOlO, L1020, L1025, L1030, 
L1040, LIOSO, L1060, L1070, L1080, L108S, L1090, LI 100, LI 110, LI 120, L1200, L1210, L1220, L1230, L1240, 
L1250, L1260, L1270, L1280, L1290, L1300, L1310, L1499, LISOO, LIS 10, L1S20, L1600, L1610, L1620, L1630, 
L1640, L16S0, L1660, L1680, L168S, L1686, L1700, L1710, L1720, L1730, L17S0, L17S5, L1800, L1810, L1815, 
L1820, L182S, L1830, L1832, L1834, L1840, L1844, L1845, L1846, L1850, L185S, L18S8, L1860, L1870, L1880, 
L1900, L1902, L1904, L1906, L1910, L1920, L1930, L1940, L1945, L1950, L1960, L1970, L1980, L1990, L2000, 
L2010, L2020, L2030, L2036, L2037, L2038, L2040, L2050, L2060, L2070, L2080, L2090, L2102, L2104, L2106, 
L2108, L2112, L2114, L2116, L2122, L2124, L2126, L2128, L2132, L2134, L2136, L2180, L2182, L2184, L2186, 
L2188, L2190, L2192, L2200, L2210, L2220, L2230, L2240, L22S0, L2260, L2265, L2270, L2280, L2300, L2310, 
L2320, L2330, L233S, L2340, L23S0, L2360, L2370, L237S, L2380, L238S, L2390, L239S, L2405, L2415, L2425, 
L243S, L2492, L2500, L2S10, L2520, L2525, L2S26, L2530, L2S40, L2S50, L2570, L2580, L2600, L2610, L2620, 
L2622, L2624, L2627, L2628, L2630, L2640, L26S0, L2660, L2670, L2680, L2750, L2760, L2770, L2780, L2785, 
L279S, L2800, L2810, L2820, L2830, L2840, L28S0, L2999, L3000, L3001, L3002, L3003, L3010, L3020, L3030, 
L3040, L3050, L3060, L3070, L3080, L3090, L3100, L3140, L3150, L3170, L3201, L3202, L3203, L3204, L3206, 
L3207, L3208, L3209, L3211, L3212, L3213, L3214, L3215, L3216, L3217, L3218, L3219, L3221, L3222, L3223, 
L3230, L3250, L32S1, L32S2, L3253, L32S4, L3255, L32S7, L3260, L326S, L3300, L3310, L3320, L3330, L3332, 
L3334, L3340, L33S0, L3360, L3370, L3380, L3390, L3400, L3410, L3420, L3430, L3440, L3450, L3455, L3460, 
L346S, L3470, L3480, L348S, L3S00, L3S10, L3520, L3S30, L3S40, L3SS0, L3S60, L3570, L3S80, L3S90, L359S, 
L3600, L3610, L3620, L3630, L3640, L3649, L3650, L3660, L3670, L3700, L3710, L3720, L3730, L3740, L3800, 
L3805, L3810, L381S, L3820, L382S, L3830, L383S, L3840, L3845, L38S0, L38S5, L3860, L3900, L3901, L3902, 
L3904, L3906, L3907, L3908, L3910, L3912, L3914, L3916, L3918, L3920, L3922, L3924, L3926, L3928, L3930, 
L3932, L3934, L3936, L3938, L3940, L3942, L3944, L3946, L3948, L3950, L3952, L39S4, L3960, L3962, L3963, 

Appendix 11-37 



Technical Note A (Continued) 

L3964, L3965, L3966, L3968, L3969, L3970, L3972, L3974, L3980, L3982, L3984, L3985, L3986, L3995, L3999, 
L4000, L4010, L4020, L4030, L4040, L4045, L4050, L4055, L4060, L4070, L4080, L4090, L4100, L4110, L4130, 
L4200, L4210, L4310, L4320, L4350, L4360, L4370, L4380, L5000, L5010, L5020, L5050, L5060, L5100, L5105, 
L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5300, L5310, L5320, L5330, L5340, L5400, 
L5410, L5420, L5430, L5450, L5460, L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, 
L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5616, L5618, L5620, L5622, L5624, L5626, L5628, L5629, 
L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, 
L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5658, L5660, L5661, L5662, L5663, L5664, 
L5665, L5666, L5668, L5670, L5672, L5674, L5675, L5676, L5677, L5678, L5680, L5682, L5684, L5686, L5688, 
L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5699, L5710, L5711, L5712, L5714, L5716, L5718, L5722, 
L5724, L5726, L5728, L5780, L5785, L5790, L5795, L5810, L5811, L5812, L5816, L5818, L5822, L5824, L5828, 
L5830, L5850, L5910, L5920, L5940, L5950, L5960, L5970, L5972, L5974, L5976, L5978, L5980, L5982, L5984, 
L5986, L5999, L6000, L6010, L6020, L6050, L6055, L6100, L6110, L6120, L6130, L6200, L6205, L6250, L6300, 
L6310, L6320, L6350, L6360, L6370, L6380, L6382, L6384, L6386, L6388, L6400, L6450, L6500, L6550, L6570, 
L6580, L6582, L6584, L6586, L6588, L6590, L6600, L6605, L6610, L6615, L6616, L6620, L6623, L6625, L6628, 
L6629, L6630, L6632, L6635, L6637, L6640, L6641, L6642, L6645, L6650, L6655, L6660, L6665, L6670, L6672, 
L6675, L6676, L6680, L6682, L6684, L6686, L6687, L6688, L6689, L6690, L6691, L6692, L6700, L6705, L6710, 
L6715, L6720, L6725, L6730, L6735, L6740, L6745, L6750, L6755, L6765, L6770, L6775, L6780, L6790, L6795, 
L6800, L6805, L6806, L6807, L6808, L6809, L6810, L6825, L6830, L6835, L6840, L6845, L6850, L6855, L6860, 
L6865, L6867, L6868, L6870, L6872, L6873, L6875, L6880, L6890, L6895, L6900, L6905, L6910, L6915, L6920, 
L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L7010, L7015, L7020, L7025, 
L7030, L7035, L7040, L7045, L7160, L7165, L7170, L7180, L7185, L7186, L7190, L7191, L7260, L7261, L7266, 
L7272, L7274, L7360, L7362, L7364, L7366, L7499, L7500, L7510, L8000, L8010, L8020, L8030, L8100, L8110, 
L8120, L8130, L8140, L8150, L8160, L8170, L8180, L8190, L8200, L8210, L8220, L8230, L8300, L8310, L8320, 
L8330, L8400, L8410, L8415, L8420, L8430, L8435, L8440, L8460, L8465, L8470, L8480, L8499, L8500, L8501, 
L8600, L8605, L8610, L8611, L8612, L8613, L8614, L8615, L8616, L8617, L8618, L8620, L8621, L8622, L8623, 
L8624, L8625, L8626, L8627, L8628, L8629, L8630, L8640, L8641, L8642, L8655, L8656, L8657, L8658, L8670, 
L8680, L8690, L9999 

Die, Oxygen and Supplies 

E0400, E0405, E0410, E0415, E0416, E0424, E0425, E0430, E0431, E0434, E0435, E0439, E0440, E0441, E0442, 
E0443, E0444, E0450, E0451, E0452, E0453, E0455, E0457, E0458, E0459, E0460, E0461, E0462, E0480, E1353, 
E1355, E1372, E1375, E1377, E1378, E1379, E1380, E1381, E1382, E1383, E1384, E1385, E1388, E1389, E1390, 
E1391, E1392, E1393, E1394, E1395, E1396, E1399, E1400, E1401, E1402, E1403, E1404, E1405, E1406, Q0036, 
Q0037, Q0038, Q0039, Q0040, Q0041, Q0042, Q0043, Q0044, Q0045, Q0046 

DID, Wheelchairs 

E0950, E0951, E0952, E0953, E0954, E0958, E0959, E0961, E()962, E0963, E0964, E0965, E0966, E0967, E0968, 
E0969, E0970, E0971, E0972, E0973, E0974, E0975, E0976, E0977, E0978, E0979, E0980, E0990, E0991, E0992, 
E0993, E0994, E0995, E0996, E0997, E0998, E0999, ElOOO, ElOOl, E1031, E1050, E1060, E1065, E1066, E1069, 
E1070, E1083, E1084, E1085, E1086, E1087, E1088, E1089, E1090, E1091, E1092, E1093, EllOO, ElllO, E1130, 
E1140, E1150, E1160, E1170, E1171, E1172, E1180, E1190, E1195, E1200, E1210, E1211, E1212, E1213, E1220, 
E1221, E1222, E1223, E1224, E1225, E1226, E1227, E1228, E1230, E1240, E1250, E1260, E1270, E1280, E1285, 
E1290, E1295, E1296, E1297, E1298, KOOOl, K0002, K0003, K0004, K0005, K0006, K0007, K0008, K0009, 
KOOlO, KOOll, K0012, K0013, K0014, K0015, K0016, K0017, K0018, K0019, K0020, K0021, K0022, K0023, 
K0024, K0025, K0026, K0027, K0028, K0029, K0030, K0031, K0032, K0033, K0034, K0035, K0036, K0037, 
K0038, K0039, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0048, K0049, K0050, K0051, 
K0052, K0053, K0054, K0055, K0056, K0057, K0058, K0059, K0060, K0061, K0062, K0063, K0064, K0065, 
K0066, K0067, K0068, K0069, K0070, K0071, K0072, K0073, K0074, K0075, K0076, K0077, K0078, K0079, 
K0080, K0081, K0082, K0083, K0084, K0085, K0086, K0087, K0088, K0089, K0090, K0091, K0092, K0093, 
K0094, K0095, K0096, K0097, K0098, K0099, KOlOO, KOlOl, K0102, K0103, K0104, K0105, K0106, K0107, 
K0108, K0109, KOI 14 

Appendix 11-38 



Technical Note A (Continued) 

DIE, Other DME 

E0669, E0670, KOI 10, KOI 11, KOI 12, KOI 13, KOI 18, Q0079, Q0080, Q0081 

DIP, Orthotic Devices 

KOI 15, KOI 16, KOI 17, K0126, K0127, K0128, K0129, K0130, K0163, L0984, L2275, L2397, L5614, L5667, L5669, 
L5700, L5701, L5702, L5704, L5705, L5706, L5707, L5840, L5855, L5925, L5962, L5964, L5966, L5979, L5981, 
L8485, L8490, Q0117, Q0118, Q0119, Q0120, Q0121, Q0122, Q0123 

(6) Other 

OLA, Ambulance 

AOOlO, A0020, A0021, A0030, A0040, A0050, A0060, A0070, A0080, A0090, AOlOO, AOllO, A0120, A0130, 
A0140, A0150, A0160, A0170, A0180, A0190, A0200, A0210, A0215, A0220, A0221, A0222, A0223, A0225, 
A0999 

OIB, Chiropractic 

A2000 

OIC, Enteral and Parenteral 

B4034, B4035, B4036, B4081, B4082, B4083, B4084, B4150, B4151, B4152, B4153, B4154, B4155, B4156, B4164, 
B4168, B4172, B4176, B4178, B4180, B4184, B4186, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, 
B5000, B5100, B5200, B9000, B9002, B9004, B9006, B9998, B9999, E0776, E0781, E0782, E0791, K0147 

OlD, Chemotherapy 

96542, 96545, J1440, J1441, J2820, J9000, J9010, J9020, J9031, J9040. J9045, J9050, J9060, J9062, J9070, J9080, 
J9090, J9091, J9092, J9093, J9094, J9095, J9096, J9097, J9100, J9110, J9120, J9130, J9140, J9150, J9165, J9170, 
J9181, J9182, J9185, J9190, J9200, J9202, J9208, J9209, J9211, J9212, J9213, J9214, J9215, J9216, J9217, J9218, 
J9230, J9240, J9250, J9260, J9265, J9268, J9270, J9280, J9290, J9291, J9293, J9295, J9300, J9320, J9340, J9360, 
J9370, J9375, J9380, J9999, Q0083, Q0084, Q0085, Q0094, Q0125 

OlE, Other Drugs 

JOllO, J0120, J0150, J0170, J0190, J0205, J0210, J0220, J0230, J0240, J0256, J0280, J0290, J0300, J0330, J0340, 
J0360, J0380, J0390, J0400, J0460, J0470, J0475, J0500, JOS 10, J0515, J0520, J0530, J0540, J0550, J0560, J0570, 
J0580, J0585, J0590, J0600, J0610, J0620, J0630, J0635, J0640, J0670, J0680, J0690, J0694, J0695, J0696, J0697, 
J0698, J0700, J0710, J0720, J0725, J0730, J0743, J0745, J0760, J0770, J0780, J0790, J0800, J0810, J0820, J0830, 
J0840, J0895, J0900, J0945, J0970, JIOOO, J1020, J1030, J1040, J1050, J1055, J1060, J1070, J1080, J1090, JllOO, 
JlllO, J1120, J1155, J1160, J1165, J1170, J1180, J1200, J1205, J1212, J1230, J1240, J1245, J1320, J1330, J1340, 
J1350, J1360, J1380, J1390, J1410, J1435, J1436, J1455, J1460, J1470, J1480, J1490, J1500, J1510, J1520, J1530, 
J1540, J1550, J1560, J1561, J1570, J1580, J1600, J1630, J1631, J1640, J1660, J1670, J1690, J1700, J1710, J1720, 
J1730, J1739, J1741, J1760, J1770, J1780, J1790, J1800, J1810, J1820, J1840, J1850, J1885, J1890, J1910, J1930, 
J1940, J1960, J1970, J1980, J1990, J2000, J2010, J2050, J2060, J2100, J2150, J2160, J2175, J2180, J2190, J2210, 
J2240, J2270, J2275, J2320, J2321, J2322, J2330, J2350, J2360, J2370, J2400, J2405, J2410, J2440, J2460, J2480, 
J2490, J2495, J2510, J2515, J2520, J2540, J2545, J2550, J2560, J2590, J2595, J2600, J2640, J2650, J2670, J2672, 
J2675, J2680, J2690, J2700, J2710, J2720, J2730, J2760, J2765, J2790, J2800, J2810, J2825, J2860, J2910, J2912, 
J2914, J2920, J2930, J2950, J2970, J2995, J2996, J3000, J3010, J3050, J3070, J3080, J3105, J3120, J3130, J3140, 
J3150, J3180, J3230, J3240, J3250, J3260, J3270, J3280, J3301, J3302, J3303, J3310, J3320, J3340, J3350, J3360, 
J3364, J3365, J3370, J3380, J3390, J3400, J3410, J3420, J3430, J3450, J3470, J3490, J3500, J3520, J3530, J3535, 
J3540, J3550, J3560, J3570, J6015, J7010, J7020, J7030, J7040, J7042, J7050, J7051, J7060, J7070, J7080, J7090, 
J7100, J7110, J7120, J7130, J7140, J7150, J7190, J7192, J7194, J7196, J7197, J7500, J7501, J7502, J7503, J7504, 
J7505, J7506, J7610, J7615, J7620, J7625, J7627, J7630, J7640, J7650, J7651, J7652, J7653, J7654, J7655, J7660, 
J7665, J7670, J7672, J7675, J7699, J7799, KOI 19, K0120, K0121, K0122, K0123, K0124, K0125, K0166, K0167, 



Appendix 11-39 



Technical Note A (Continued) 



Q9920, Q9921, Q9922, Q9923, Q9924, Q9925, Q9926, Q9927, Q9928, Q9929, Q9930, Q9931, Q9932, Q9933, 
Q9934, Q9935, Q9936, Q9937, Q9938, Q9939, Q9940 



OIF, Vision, Hearing 

K0162, Q0093, 
V2110, V2111, 
V2204, V2205, 
V2218, V2219, 
V2310, V2311, 
V2499, V2500, 
V2599, V2600, 
V2630, V2631, 
V2755, V2760, 
V5014, V5016, 
V5140, V5150, 
V5321, V5322, 



and Speech Services 

V2020, V2025, V2100, 
V2112, V2113, V2114, 
V2206, V2207, V2208, 
V2220, V2299, V2300, 
V2312, V2313, V2314, 
V2501, V2502, V2503, 
V2610, V2615, V2620, 
V2632, V2700, V2710, 
V2770, V2780, V2785, 
V5020, V5030, V5040, 
V5160, V5170, V5180, 
V5330, V5335, V5336, 



V2101, V2102, V2103, V2104, V2105, V2106, V2107, V2108, V2109, 
V2115, V2116, V2117, V2118, V2199, V2200, V2201, V2202, V2203. 
V2209, V2210, V2211, V2212, V2213, V2214, V2215, V2216, V2217, 
V2301, V2302, V2303, V2304, V2305, V2306, V2307, V2308, V2309, 
V2315, V2316, V2317, V2318, V2319, V2320, V2399, V2410, V2430, 
V2510, V2511, V2512, V2513, V2520, V2521, V2522, V2523, V2530, 
V2621, V2622, V2623, V2624, V2625, V2626, V2627, V2628, V2629, 
V2715, V2718, V2730, V2740, V2741, V2742, V2743, V2744, V2750, 
V2799, V5000, V5001, V5002, V5003, V5008, V5010, V5011, V5012, 
V5050, V5060, V507O, V5080, V5090, V5100, V5110, V5120, V5130, 
V5190, V5200, V5210, V5220, V5230, V5240, V5299, V5301, V5310, 
V5360, V5362, V5363, V5364 



OIG, Influenza Immunization 

90724, Q0124 



(6) Exceptions/Unclassified 



Yl , Other - Medicare Fee Schedule 

23929, 26989, 29909, 69949, 92392, 92393, 92395, 92396, 96546, 96549, 99002, 99024, 99050, 99052, 99054, 99056, 
99070, 99071, 99078, 99080, 99082, 99090, 99199, 99358, 99359, 99371, 99372, 99373, 99375, 99376, DOllO, 



D0120, D0130 
D0320, D0321 
D0999, DlllO 
D1525, D1550 
D2335, D2336 
D2540, D2610 
D2750, D2751 
D2950, D2951 
D3310, D3320 
D3425, D3426 
D4211, D4220 
D4340, D4341 
D5215, D5216, 
D5650, D5660 
D5810, D5811 
D5915, D5916 
D5929, D5931 
D5957, D5958 
D5987, D5988 
D6240, D6241 
D6751, D6752 
D6980, D6999 
D7272, D7280, 
D7431, D7440 
D7540, D7550, 
D7740, D7750 
D7860, D7865 



D0210, D0220, D0230, D0240, D0250 
D0322, D0330, D0340, D0410, D0415 
D1120, D1201, D1202, D1203, D1204 
D2110, D2120, D2130, D2131, D2140 
D2380, D2381, D2382, D2385, D2386 
D2620, D2630, D2640, D2650, D2651 
D2752, D2790, D2791, D2792, D2810 
D2952, D2953, D2954, D2960, D2961 
D3330, D3340, D3346, D3347, D3348 
D3430, D3440, D3450, D3460, D3470, 
D4240, D4249, D4250, D4260, D4261 
D4345, D4910, D4920, D4999, D5110 
D5280, D5281, D5410, D5411, D5421 
D5710, D5711, D5720, D5721, D5730 
D5820, D5821, D5850, D5851, D5860 
D5917, D5918, D5919, D5920, D5921 
D5932, D5933, D5934, D5935, D5936 
D5959, D5960, D5971, D5972, D5973 
D5999, D6030, D6040, D6050, D6055 
D6242, D6250, D6251, D6252, D6520 
D6780, D6790, D6791, D6792, D6930 
D7110, D7120, D7130, D7210, D7220 
D7281, D7285, D7286, D7290, D7291 
D7441, D7450, D7451, D7460, D7461 
D7560, D7610, D7620, D7630, D7640 
D7760, D7770, D7780, D7810, D7820 
D7870, D7872, D7873, D7874, D7875 



D0260, D0270, D0272, D0274, D0275, D0290, D0310, 
D0420, D0425, D0460, D0470, D0471, D0501, D0502, 
D1205, D1310, D1330, D1351, D1510, D1515, D1520, 
D2150, D2160, D2161, D2210, D2330, D2331, D2332, 
D2387, D2410, D2420, D2430, D2510, D2520, D2530, 
D2652, D2660, D2710, D2720, D2721, D2722, D2740, 
D2910, D2920, D2930, D2931, D2932, D2933, D2940, 
D2962, D2970, D2980, D2999, D3110, D3120, D3220, 
D3350, D3351, D3352, D3353, D3410, D3411, D3421, 
D3910, D3920, D3940, D3950, D3960, D3999, D4210, 
D4262, D4268, D4270, D4271, D4272, D4320, D4321, 
D5120, D5130, D5140, D5211, D5212, D5213, D5214, 
D5422, D5510, D5520, D5610, D5620, D5630, D5640, 
D5731, D5740, D5741, D5750, D5751, D5760, D5761, 
D5861, D5862, D5899, D5911, D5912, D5913, D5914, 
D5922, D5923, D5924, D5925, D5926, D5927, D5928, 
D5937, D5951, D5952, D5953, D5954, D5955, D5956, 
D5974, D5976, D5982, D5983, D5984, D5985, D5986, 
D6080, D6090, D6100, D6199, D6210, D6211, D6212, 
D6530, D6540, D6545, D6720, D6721, D6722, D6750, 
D6940, D6950, D6970, D6971, D6972, D6973, D6975, 
D7230, D7240, D7241, D7250, D7260, D7270, D7271, 
D7310, D7320, D7340, D7350, D7410, D7420, D7430, 
D7465, D7470, D7480, D7490, D7510, D7520, D7530, 
D7650, D7660, D7670, D7680, D7710, D7720, D7730, 
D7830, D7840, D7850, D7852, D7854, D7856, D7858, 
D7876, D7877, D7880, D7899, D7910, D7911, D7912, 



Appendix 11-40 



Technical Note A (Continued) 

D7920, D7940, D7941, D7942, D7943, D7944, D7945, D7946, D7947, D7948, D7949, D7950, D7955, D7960, 
D7970, D7971, D7980, D7981, D7982, D7983, D7990, D7991, D7992, D7993, D7994, D7999, D8110, D8120, 
D8210, D8220, D8360, D8370, D8460, D8470, D8480, D8560, D8570, D8580, D8650, D8750, D8999, D9110, 
D9210, D9211, D9212, D9215, D9220, D9221, D9230, D9240, D9310, D9410, D9420, D9430, D9440, D9610, 
D9630, D9910, D9920, D9930, D9940, D9941, D9950, D9951. D9952, D9960, D9999, H5010, H5020, H5025, 
H5030, H5040, H5050, H5060, H5090, H5100, H5110, H5120, H5130, H5160, H5170, H5180, H5190, H5200, 
H5220, H5230, H5240, H5299, H5300, Q0068, Q1024 

Y2 , Other - Non Medicare Fee Schedule 

90699, 92390, 92391, 98920, 98921, 98922, 99075, 99360, E0755, M0009, M0019, M0071, M0075, M0076, M0300, 
M0799, P9005, P9007, P9010, P9011, P9012, P9013, P9014, P9015, P9016, P9017, P9018, P9019, P9020, P9021, 
P9022, P9023, P9024, P9603, P9604, Q0034, Q0060, Q0061, Q0108 

Zl, Local Codes 

All W, X, Y, and Z 

Z2 , Undefined codes. 

22500, 36020, 49910, 62286, 70002, 75996, 88157, 90898, 97545, 97546, 99013, 99014, 99015, 99499, M0020, 
M0299, M0302, M0700, M9999, P2000, P7000, P9000, P9006, Q0057, Q0063, Q0066, Q0069, Q0070, Q0071, 
Q0072, Q0073, Q0074, Q0077, Q0078, Q0082, Q0086, Q0087, Q0088, Q0089, Q0090, Q0093, QQOOl, QQ002, 
QQ003, QQ004, QQ005, R0009, R0059, R0085, R0109, R0129, R0159, R0209, R0259, R0309, R0359, R0599 



Appendix 11-41 



Technical Note B 
Health Resource Profile Code Definitions 



Metropolitan Counties 
Large Metropolitan: 
Core Counties 



Fringe Counties 

Medium Metropolitan 

Lesser Metropolitan 

Non Metropolitan Counties 

Urbanized: 
Adjacent to MSA 



Core counties of metropolitan areas of 1,000,000 or more 
population 

Noncore counties of metropolitan areas of 1,000,000 or more 
population 

Counties of metropolitan areas of 250,000 to 999,999 population 

Counties of metropolitan areas of 50,000 to 249,999 population 



Counties contiguous to MSA with 20,000 or more urban 
residents 



Not Adjacent to MSA Counties not contiguous to MSA with 20,000 or more urban 

residents 



Less Urbanized: 
Adjacent to MSA 



Not Adjacent to MSA 



Thinly Populated: 

Adjacent to MSA 

Not Adjacent to MSA 



Counties contiguous to MSA with less than 20,000 but greater 
or equal to 2,500 urban residents 

Counties not contiguous to MSA with less than 20,000 but 
greater or equal to 2,500 urban residents 



Counties contiguous to MSA with no urban residents 
Counties not contiguous to MSA with no urban residents 



** Note: 

1) Non-adjacent = Non contiguous counties and contiguous counties having less than 1 
percent of labor force commuting to the MSA. 

2) Urban = Place or township, incorporated or unincorporated, of 2,500 or more population. 



Appendix 11-42 



Technical Note C 

PPR Payment Impacts, Ordered by State Impact 
(Fed Reg Vol 56(227) Nov 25, 1991 page 59619) 



State 



Percent Change in Allowed Charges 

for Fee Schedule Relative to CPR: 

Payments per Service: 1996 



United States 


-6 


Mississippi 


12 


Iowa 


9 


Colorado 


9 


Wyoming 


8 


Minnesota 


7 


New Hampshire 


6 


Utah 


5 


Idaho 


6 


South Carolina 


4 


Michigan 


4 


Virginia 


4 


Vermont 


2 


Missouri 


1 


Nebraska 


1 


Rhode Island 


1 


Maine 


1 


Kentucky 





South Dakota 





Washington 


-1 


Wisconsin 


-1 


Montana 


-2 


North Carolina 


-2 


Tennessee 


-2 


Oregon 


-2 


Indiana 


-2 


Oklahoma 


-3 


Massachusetts 


-3 



Ex Ante Impact 


Increase 


Increase 


Increase 


Increase 


Increase 


Increase 


Increase 


Increase 


Increase 


Increase 


Increase 


No Change 


No Change 


No Change 


No Change 


No Change 


No Change 


No Change 


No Change 


No Change 


No Change 


No Change 


No Change 


No Change 


No Change 


No Change 


No Change 



Appendix 11-43 



Technical Note C (cont) 



PPR Payment Impacts, Ordered by State Impact 
(Fed Reg Vol 56(227) Nov 25, 1991 page 59619) 



State 
United States 



Percent Change in Allowed Charges 
for Fee Schedule Relative to CPR: 
Payments per Service: 1996 



Ex Ante Impact 



Pennsylvania 
New Jersey 
Kansas 
Delaware 
Illinois 

North Dakota 
Georgia 
Alabama 
Arkansas 
West Virginia 
Lousiana 
District of Col. 
Ohio 

Connecticut 
New York 
New Mexico 

Maryland 

Texas 

Arizona 

California 

Hawaii 

Florida 

Alaska 

Nevada 



-4 
-4 
-4 
-4 
-5 
-5 
-6 
-6 
-7 
-7 
-7 
-7 
-7 
-8 
-8 
-9 

-10 
-11 
-13 
-14 
-16 
-17 
-19 
-20 



Moderate 
Moderate 
Moderate 
Moderate 
Moderate 
Moderate 
Moderate 
Moderate 
Moderate 
Moderate 
Moderate 
Moderate 
Moderate 
Moderate 
Moderate 
Moderate 

Large 
Large 
Large 
Large 
Large 
Large 
Large 
Large 



Decrease 
Decrease 
Decrease 
Decrease 
Decrease 
Decrease 
Decrease 
Decrease 
Decrease 
Decrease 
Decrease 
Decrease 
Decrease 
Decrease 
Decrease 
Decrease 

Decrease 
Decrease 
Decrease 
Decrease 
Decrease 
Decrease 
Decrease 
Decrease 



Appendix 11-44 



Appendix III 
Monitoring Part A 



Prepared by: A. Marshall McBean, M.D. 

Leslye Fitterman 

Office of Research and Demonstrations 

Health Care Financing Administration 

April 1994 

Revised May 31, 1994 



Appendix III 

Monitoring Part A 

INTRODUCTION 

One of the intents of the Medicare fee schedule (MFS) is to shift Medicare payments 
away from surgical services toward primary care services. It is important, therefore, to 
monitor the impact of the MFS on access to, and utilization of, surgical services for 
vulnerable subgroups of the Medicare population. 

The purpose of this analysis is to monitor trends on the use of surgical procedures 
performed in the hospital for a vulnerable subgroup of the Medicare population - black 
beneficiaries. It focuses primarily on changes in the procedure rates among white and 
black Medicare beneficiaries in the period 1990 through 1992, the initial period of 
implementation of the MFS. These data will be updated as new information becomes 
available. 

Recent studies examining the utilization rates of procedures show differences by race 
that are not well understood. A detailed report on the experience of Medicare 
beneficiaries hospitalized in 1986 showed that for selected procedures, rates were 
consistently lower for black beneficiaries compared to white beneficiaries (Health Care 
Financing Administration (HCFA), 1990). Reports prepared by the Health Care 
Financing Administration and by the Physician Payment Review Commission, and 
included in the 1992 and 1993 access reports to Congress, indicated that differences by 
race in the rate of selected procedures persisted throughout the later part of the 1980s 
(HCFA, 1992; HCFA, 1993; PPRC, 1992). A study by Udvarhelyi et al. (1992), 
examining procedures performed for Medicare patients hospitalized with acute 
myocardial infarction (AMI), found that black beneficiaries and women had substantially 
lower rates of catheterization, coronary artery bypass graft (CABG) and percutaneous 
transluminal coronary angioplasty (PTCA) in the 90 days following the AMI. Whittle et 
al. (1993) reported that white veterans were more likely than black veterans to undergo 
invasive cardiac procedures (cardiac catheterization, PTCA or CABG) in the Veterans 
Affairs Medical System between 1987 and 1991. Escarce et al. (1993) used 1986 
Medicare Part B physicians claims data for a 5-percent sample of elderly Medicare 
beneficiaries to study 32 diagnostic and therapeutic procedures. White persons were 
more likely to receive 23 of the services, particularly the higher technology or newer 
services. Black persons were more likely to receive seven of the services. They felt 
that the differences could not be explained by the prevalence of specific clinical 
conditions in the population, that financial barriers to care did not fully account for the 
findings, and that race may exacerbate the impact of other barriers to access. 

We have used another measure to help interpret differences in procedure rates among 
black and white Medicare beneficiaries, the 30-day post-admission mortality rate 
(HCFA, 1990; HCFA, 1992; and HCFA, 1993). Higher post-admission mortality rates 

Appendix III-l 



in a population group may indicate that a greater proportion of those hospitalized for 
the procedure are more severely ill. This may be due to differences in patient behavior 
in seeking care, provider behavior, or health care system factors such as coinsurance. 
An alternative explanation is that the quality of care received by one group differs from 
that received by the other group, especially if different population groups are routinely 
treated by different providers. 

This analysis provides rates at which white and black beneficiaries were hospitalized for 
18 major procedures in 1990 and 1992. The procedures were selected either for their 
frequency, or the lack of agreement about their outcomes and effectiveness, or cost. 
Included are procedures ranging from newer, "high tech" ones such as percutaneous 
transluminal coronary angioplasty (PTCA), coronary artery bypass graft (CABG) 
surgery, and total knee replacement (TKR) to traditional procedures such as 
appendectomy and inguinal hernia repair. 

METHODS 

Sources of Data 

Data were derived from the Medicare Provider Analysis and Review (MEDPAR) file 
for the two calendar years, 1990 and 1992. The MEDPAR file for each year contains 
one record for each Medicare-covered stay in a short-stay hospital with a date of 
discharge in that year. Each record contains dates of admission and discharge, up to 
five diagnoses in 1990 and nine diagnoses in 1992, and up to three procedures in 1990 
and six procedures in 1992. (The first listed is the principal diagnosis - the condition 
established after study to be chiefly responsible for occasioning the admission of the 
patient to the hospital.) Diagnoses and procedures are coded using the International 
Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). 
Appendix II, Technical Note A contains the codes used to identify the procedures 
described in the tables. Date of death, obtained from Medicare enrollment files, is 
appended to the record to track death after discharge from the hospital. Enrollment 
data from the Medicare denominator files for 1990 and 1992 were used to create rates 
of use. For Medicare beneficiaries enrolled in health maintenance organizations 
(HMOs) hospital stay records are incomplete. Therefore, records for HMO enrollees 
(about 6 percent of all beneficiaries) were eliminated from all files. 

Measures 

A procedure was counted if it appeared in any of the fields reserved on the record for 
procedures. Rates per 1,000 Medicare beneficiaries were age and sex adjusted by the 
direct method, using the 1986 age-sex composition of the Medicare population as the 
standard. 

The 30-day post-admission death rate is the rate of death within 30 days of admission 
per 1,000 discharges. The 30-day post-admission death rates for each procedure were 

Appendix III-2 



age and sex adjusted by the direct method, using the 1986 distribution of discharges for 
that procedure as the standard. 



Statistical Analysis 

The 1990 and 1992 procedure rates and the 30-day post-admission mortality rates were 
compared using the chi-square statistic. Comparisons between the percent changes in 
the rates among black beneficiaries versus white beneficiaries were tested using 
t-statistics. 

RESULTS 

Table III-l shows the discharge rates in 1990 and 1992 for all the procedures included 
in these analyses. The first four include one diagnostic procedure (cardiac 
catheterization) as well as the rates for PTCA, CABG, and carotid endarterectomy, 
three relatively discretionary therapeutic cardiovascular procedures. In 1990, the rate 
for CABG among white beneficiaries (3.64 procedures per 1,000 enrollees) was 
substantially higher than the rate for black beneficiaries (1.34 procedures per 1,000 
enrollees). In fact, all four procedures were performed at a substantially higher rate for 
white beneficiaries compared to black beneficiaries. The ratios of the discharge rates 
(black: white) for these procedures were 0.30 for carotid endarterectomy, 0.37 for CABG 
surgery, 0.40 for PTCA, and 0.65 for cardiac catheterization. 

By 1992, the rate of PTCA was greater than the rate of CABG for both races. During 
the two-year period, the rates for all four procedures increased significantly for both 
race groups. The increases were between 17.15 percent for cardiac catheterization 
among white persons and 56.74 percent for PTCA among black persons. All rates for 
the therapeutic procedures increased by over 30 percent. In all cases the increase in 
the rates was greater among black beneficiaries than among white beneficiaries. Thus, 
the ratios (black:white) all increased between 1990 and 1992, indicating that the 
disparities by race for each of these procedures diminished during the period 1990 
through 1992. 

Table III-l also shows that in 1990 and 1992, the 30-day post-admission death rates per 
1,000 discharges were higher for black beneficiaries than for white beneficiaries for all 
three therapeutic procedures suggesting that black beneficiaries undergoing these 
procedures are, on average, more severely ill than white beneficiaries. 

Between 1990 and 1992, the 30-day post-admission mortality rates decreased for both 
black and white beneficiaries following PTCA and carotid endarterectomy, although the 
difference was statistically significant (p < 0.01) only for white persons following carotid 
endarterectomy. However, following CABG surgery, the 30-day post-admission 
mortality rate increased for both race groups, and that increase was statistically 
significant (p < 0.01) for white persons (23.43 percent in two years). During this 

Appendix III-3 



period, the ratio (black: white) of the 30-day post admission death rate decreased 
following PTCA and CABG, suggesting that the severity of the patient mix is becoming 
more alike for black and white beneficiaries. 

Table III-l also shows procedure rates and 30-day post-admission death rates for 
orthopedic and back procedures in 1990 and 1992. Procedure rates increased for all 
seven procedures for both races. The greatest increases were for the two newest 
orthopedic procedures, total hip replacement and total knee replacement. For total 
knee replacement, there was a two-year increase of 28.70 percent in white persons and 
32.67 percent in black persons. Corresponding figures for hip replacement were 5.56 
percent and 14.04 percent. Thus, the black:white ratio for these two procedures 
increased between 1990 and 1992. For reduction of fracture of the femur and other 
arthroplasty of the hip, the procedure rates and the 30-day post-admission mortality rate 
were substantially greater in white persons than in black persons in both years, very 
likely reflecting the higher incidence of osteoporosis and the greater severity of that 
illness in white beneficiaries. 

The greatest increases in the back procedure rates between 1990 and 1992 were in 
spinal fusion which increased by 39.13 percent in white beneficiaries and 42.86 percent 
in black beneficiaries. The blackrwhite ratio increased for spinal fusion, remained the 
same for excision of disk and decreased for laminectomy. The 30-day post-admission 
mortality rates among white persons decreased between 14.30 percent and 26.87 
percent for the back procedures. The blackrwhite ratios for the 30-day post-admission 
mortality rates decreased only for excision of disk. 

Procedure rates and 30-day post-admission mortality rates are also shown for seven 
procedures performed commonly among Medicare beneficiaries (Table III-l). In the 
five years prior to 1990, these procedures had minimal or no major technological 
changes nor major increases in rates. The decreases in the cholecystectomy rates by 
1992 suggest that laparoscopic cholecystectomy was performed with increasing frequency 
in the elderly. Thus, open (non-laparoscopic) cholecystectomy rates decreased by 
44.76 percent in white Medicare beneficiaries and by 33.84 percent in black 
beneficiaries. The same time period saw a decrease in both races of the rates of 
incidental appendectomy which is probably related to the large decrease in the rate of 
open cholecystectomy. The rate for in-hospital inguinal hernia repair decreased for 
both race groups, and the decrease was almost two times as great in white beneficiaries 
(30.77 percent) as in black beneficiaries (17.86). Between 1990 and 1992, the ratios 
(blackrwhite) of rates of the seven procedure presented in Table III-l increased in five 
of the procedures (prostatectomy, cholecystectomy, repair of inguinal hernia, 
mastectomy and appendectomy), remained the same in one (incidental appendectomy), 
and decreased in one (hysterectomy), indicating that the disparities by race in the use 
of these procedures is decreasing. 

For each procedure, the 30-day post-admission mortality rate was greater among black 
beneficiaries than white beneficiaries in both 1990 and 1992. In 1992, the ratio of the 

Appendix III-4 



30-day post admission mortality rates for black beneficiaries to white beneficiaries 
ranged from 1.03 for cholecystectomy to 2.35 for appendectomy. However, during the 
two-year time period, the ratio decreased for five of the seven procedures 
(cholecystectomy, repair of inguinal hernia, mastectomy, hysterectomy, and incidental 
appendectomy) suggesting that the severity of the patient mix across the two race 
groups is becoming more alike. 

DISCUSSION 

Information presented in the 1992 Access Report to Congress, Chapter 5, and the 1993 
Access Report to Congress, Chapter 3, indicated that during the 5 years 1986 through 
1990, (1) the surgical diagnosis related group (DRG) rate for black beneficiaries was 
consistently lower than among white beneficiaries, and (2) that when procedure rates 
are examined in detail (using ICD-9-CM codes), questions are raised about the 
differences in treatment patterns by race that existed in the period before 
implementation of the MFS. This chapter provides the first information examining 
these differences during the initial period of implementation of the MFS. 

Overall, a comparison of 1990 with 1992 shows an increase in the ratio (black:white) of 
the rates of the surgical procedures. Of the 18 procedures examined, the ratio 
increased in 13, remained the same in two, and decreased in three. Thus, the 
preponderance of evidence indicates that there was no reduction in utilization for the 
black population examined in this chapter by the implementation of the MFS ~ in fact, 
disparities lessened between black and white groups. This was particularly true for the 
new, high tech procedures that are often designated as "referral sensitive" procedures 
(PTCA, CABG surgery, carotid endarterectomy, total hip replacement and total knee 
replacement). Nonetheless, major differences continue to exist in the use of these 
procedures by race. 

The large differences in treatment patterns by race for new and/or more elective 
procedures is consistent with the findings by Wennberg et al. (1982) that geographic 
variations tend to be greater for procedures that are discretionary for which there are 
greater differences of opinion among physicians and patients about the appropriateness 
of performing the procedure. Thus, it is possible that individuals within the group with 
the higher rate of surgery (i.e., white beneficiaries) are undergoing procedures that may 
not be appropriate. These differences by race may also reflect a slower diffusion of 
new technologies into vulnerable subgroups of the Medicare population. Thus, in spite 
of the generally equalizing changes in the black:white ratios seen for the majority of the 
procedures black persons are still lagging far behind whites for the cardiac, orthopedic 
and back procedures with ratios of between 0.31 and 0.64 in 1992. Stated another way, 
black persons are roughly 1/3 to 2/3 as likely to have one of these procedures as white 
persons. Some of the changes shown in this chapter for cholecystectomy and repair of 
inguinal hernia may be explained by changes in technology and the use of new 
procedure codes (laparoscopic cholecystectomy), and the fact that repair of inguinal 
hernia is being more often performed on an outpatient basis. 

Appendix III-5 



Except for the procedures performed for hip fracture, the 30-day post-admission death 
rates continued to be higher for black beneficiaries than for white beneficiaries. This 
may indicate that, on average, black beneficiaries who undergo the other procedures 
described in this appendix are more severely ill than white beneficiaries or, there may 
be differences in the quality of care between the two groups. 

However, there were certain changes in the 30-day post-admission mortality rates which 
deserve comment. These rates following PTCA and carotid endarterectomy decreased 
at a time when the procedure rates increased for both races, which could reflect 
increased experience among those involved in the surgery, operating on less sick people, 
or some combination of the two. 

The patterns for CABG surgery are very different. There was a 23.43 percent increase 
in the age-sex adjusted 30-day post-admission mortality rates among white persons. The 
increase among black persons was smaller, 8.31 percent. The 30-day post-admission 
mortality rates are markedly better than those seen in 1986 through 1988 ~ 53.3 to 
59.9/1,000 discharges for white persons and 60.0 to 79.0/1,000 discharges for black 
persons (McBean et al., 1994). In the two years between 1990 and 1992, the CABG 
surgery rate increased by 31.59 percent in white persons and by 38.06 percent in black 
persons. The HCFA administrative data used in this analysis do not allow us to 
attempt to estimate the severity of illness of persons who underwent CABG surgery; 
however, the increase in CABG surgery rates and in mortality rates suggests that 
recipients of this surgery in 1992 included more severely ill patients than those in 1990. 

The large increases in the 30-day post-admission mortality rates following 
cholecystectomy and inguinal hernia repair among white persons is likely related to the 
increased number of laparoscopic cholecystectomies and the shift of many of the 
inguinal hernia repair procedures to the outpatient setting. Also, for cholecystectomy, 
those patients who begin as a laparoscopic case and then need an open procedure 
because of unforseen complications would be in our population of cholecystectomies 
and have a higher risk of post-operative mortality. 

The continuing differences by race in hospitalization and 30-day post-admission 
mortality rates for the major procedures examined here seem to indicate that treatment 
patterns are different in each race group. There are a number of factors that might 
influence differences in hospital treatment practices. Having supplemental health 
insurance may play some role. Black beneficiaries have lower rates of private insurance 
supplemental to Medicare and higher rates of Medicare/Medicaid coverage than white 
beneficiaries. However, the differences in treatment practices appear so large as to 
very likely reflect factors other than health insurance coverage. Differences in 
economic status, patient preferences, and provider opinion and selection may explain 
some of the differences by race. 



Appendix III-6 



A major impetus behind health care reform is the belief that health insurance should 
be available for every person in the Nation. These data for Medicare beneficiaries 
suggest that health insurance is a necessary, but not sufficient, condition for assuring 
that access to care is equitable for all of the population. As demonstrated, even with a 
uniform national Medicare benefit package, differences in utilization of services exist for 
beneficiaries. More detailed information of utilization and more knowledge than we 
presently have on a number of factors, including need, appropriateness, and patient 
preferences are necessary. Risk factors, health status, functional status, medical history, 
and quahty of life information, which will be collected by the Medicare Beneficiary 
Health Status Registry and the Medicare Current Beneficiary Survey, will provide 
Medicare with a better understanding of the need for surgery in the Medicare 
population. 

The 1980s saw the emergence of a trend toward the support of research relating to the 
outcomes and effectiveness of medical and surgical treatments. That initiative was 
stimulated by the large and unexplained variations across geographic areas in treatment 
practices. Continuing differences by race in Medicare procedure rates, documented in 
this chapter, underscore the importance of continuing to monitor these rates and 
developing better information about the roles of income, insurance, as well as the need 
for care by subgroups of our population. On balance, however, in spite of our 
knowledge gaps, the preponderance of evidence from the analysis of the hospital 
procedure rates and 30-day post-admission mortality rates by race indicates that the 
implementation of the MFS has not accentuated the differences in the care received by 
one of the vulnerable Medicare populations, black beneficiaries. 



Appendix III-7 



REFERENCES 

Escarce, J.J., Epstein, K.R., Colby, D.C., Schwartz, J.S. Racial differences in the 
elderly 's use of medical procedures and diagnostic tests. Am J Public Health, 83:948- 
954,1993. 

Federal Register 57/120, 39879-39893, September 1, 1992. 

Health Care Financing Administration: Hospital Data by Geographic Area for Aged 
Medicare Beneficiaries: Selected Procedures, 1986. Special Report, Volume 2, HCFA 
Pub. No. 03300, June 1990. 

Javitt, J.C., McBean, A.M., Nicholson, G.A., Babish, J.D., Warren, J.L., Krakauer, H.K. 
Undertreatment of glaucoma among black Americans. N Eng J Med 325:1418-1422, 
1991. 

McBean, A.M., Warren, J.L., Babish, J.D. Continuing differences in the rates of 
percutaneous transluminal coronary angioplasty and coronary artery bypass graft surgery 
between black and white Medicare beneficiaries. Am Heart J, 127:287-295, 1994. 

Physician Payment Review Commission: Monitoring Access of Medicare Beneficiaries, 
Report to Congress. No. 92-5, May 1992. 

Udvarhelyi, S., Gatsonis, C, Epstein, A., et al.: Acute Myocardial Infarction in the 
Medicare Population - Process of Care and Clinical Outcomes. JAMA. Vol. 268, 
No. 18, 1990. 

U.S. Social Security Administration, Office of Research and Statistics, Medicare: Health 
Insurance for the Aged, 1967, Section 4.1: Short-Stay Hospital Utilization. Washington, 
D.C. 1975. 

Wennberg, J., Barnes, B., and Zubkoff, M.: Professional Uncertainty and the Problem 
of Supplier-Induced Demand. Soc Sci Med, Vol 16. Pergamon Press Ltd. Great Britain, 
1982. 

Whittle, J., Conigliaro, J., Good, C.B., Lofgren, R.P. Racial differences in the use of 
invasive cardiovascular procedures in the Department of Medical Affairs Medical 
System. N Engl J Med 329:623-629, 1993. 



Appendix III-8 



Table III-l . Comparison of age-adjusted rates of selected procedures in elderly black and white Medicare beneficiaries, 
and 30-day post-admission death rates, 1990 and 1992. 



Procedure rate 



30-day post-admission death rate 



1990 



1992 



1990 



1992 



Number 



Black/ 
Rate/* white 
1,000 ratio 



Number 



Rate/* 
1,000 



Heart and Vascular Procedures 
Cardiac catheterization 

White 334,039 13.82 0.65 409,074 16.19 

Black 18,689 8.97 23,539 11.05 

Percutaneous transluminal coronary angioplasty (PTCA) 

White 88,594 3.56 0.40 125,610 4.98 

Black 2,942 1.41 

Coronary artery bypass graft (CABG) 

0.37 



0.30 



4,703 2.21 



White 90,749 


3.64 


Black 2.792 


1.34 


Carotid endarterectomy 




White 43,314 


1.73 


Black 1.090 


0.52 


Orthopedic and Back Procedures 


Reduction of fracture of femur 


White 121,773 


4.76 


Black 4.343 


2.02 


Other arthroplasty of hip 




White 62.945 


2.46 


Black 2,474 


1.15 


Total knee replacement 




White - 80,99a 


3.24 


Black 4,256 


2.02 


Total hip replacement 




White 63,260 


2.52 


Black 2,408 


1.14 


Laminectomy 




White 33,852 


1.36 


Black 1,536 


0.74 


Excision of disk 




White 30,589 


1.23 


Black 1,289 


0.62 


Spinal fusion 




White 11,387 


0.46 


Black 581 


0.28 


Other Procedures 




Prostatectomy 




White 226,416 


22.41 


Black 16.911 


20.44 


Cholecystectomy 




White 131,430 


5.25 


Black 6.919 


3.28 


Repair of inguinal hernia 




White 59,174 


2.34 


Black 3,489 


1.68 


Mastectomy 




White 54,284 


3.61 


Black 3,491 


2.72 


Hysterectomy 




White 51.258 


3.46 


Black 2.779 


2.19 


Appendectomy 




White 11.157 


0.45 


Black 691 


0.33 


Incidental Appendectomy 




White 10,635 


0.43 


Black 747 


0.36 



0.42 



0.47 



0.62 



0.45 



0.54 



0.50 



0.61 



0.91 



0.62 



0.72 



0.75 



0.63 



0.73 



0.84 



121,020 


4.79 


3,920 


1.85 


60,090 


2.36 


1.569 


0.73 


132,447 


4.99 


4,950 


2.21 


71.178 


2.69 


2,715 


1.21 


105,670 


4.17 


5,805 


2.68 


67,876 


2.66 


2.806 


1.3 


36.069 


1.54 


1,737 


0.81 


33,816 


1.35 


1,451 


0.68 


16,092 


0.64 


846 


0.4 


211,851 


20.55 


16,738 


19.99 


74,338 


2.9 


4.706 


2.17 


41,937 


1.62 


2.936 


1.38 


51,953 


3.43 


3,641 


2.77 


54,906 


3.67 


2.897 


2.21 


11.522 


0.45 


729 


0.34 


9,448 


0.37 


670 


0.31 



Black/ 
white 
ratio 



0.68 



0.44 



0.39 



0.31 



0.44 



0.45 



0.64 



0.49 



0.53 



0.50 



0.63 



0.97 



0.75 



0.85 



0.81 



0.60 



0.76 



0.84 



Percent 
change 
1990-92 



17.2 
23.2 

39.9 
56.7 

31.6 
38.1 

36.4 
40.4 



4.8 -I- 

9.4 + 

9.4 + 
5.2 

28.7 + 

32.7 + 

5.6 -I- 

14.0 -I- 

13.2 + 

9.5 + 

9.8 + 

9.7 + 

39.1 + 
42.9 -I- 



-8.3 + 

-2.2 -t- 

44.8 -I- 

-33.8 + 

-30.8 + 

-17.9 + 

-5.0 + 
1.8 

6.1 + 
0.9 

0.0 
3.0 

-14.0 + 

-13.9 + 



Black/ Black/ Percent 

Rate/** white Rate/** white change 
1,000 ratio 1,000 ratio 1990-92 



na 
na 

23.88 
27.59 

32.87 
42.11 

18.54 
23.66 



58.28 

45.71 

55.88 
53.35 

5.52 
8.75 

14.71 
15.42 

11.75 
18.53 

6.38 
15.48 

18.87 
20.99 



9.59 
11.31 

29.87 
39.77 

13.75 
21.1 

5.22 
8.03 

7.4 
16.41 

27.39 
47.84 

30.74 
44.77 



na 
na 

1.16 



1.28 



1.28 



0.78 



0.95 



1.59 



1.05 



1.58 



2.43 



1.11 



1.18 



1.33 



1.53 



1.54 



2.22 



1.75 



1.46 



na 
na 

23.27 
24.38 

40.57 
45.61 

15.53 
20.43 



57.51 
47.71 

55.27 
46.68 

4.28 
6.31 

13.56 
14.98 

10.07 
20.38 

5.37 
11.41 

13.8 
21.57 



9.22 
11.72 

41.01 
42.4 

16.68 
18.81 

4.96 
7.42 

7.44 
15.16 

27.64 
64.44 

34.01 
45.16 



na 
na 

1.05 



1.12 



1.32 



0.83 



0.84 



1.47 



1.10 



2.02 



2.12 



1.56 



1.27 



1.03 



1.13 



1.50 



2.04 



2.33 



1.33 



na 
na 

-2.6 
-11.6 

23.4 -I- 
8.3 

-16.2 + 
-13.7 



-1.3 
4.4 

-1.1 
-12.5 

-22.5 + 
-27.9 

-7.8 
-2.9 

-14.3 -t- 
10.0 

-15.8 
-26.3 

-26.9 -f 
2.8 



-3.9 
3.6 

37.3 + 
6.6 

21.3 + 
-10.9 

-5.0 
-7.6 

0.5 + 
-7.6 

0.9 
34.7 

10.6 

0.9 



♦ per 1 ,000 enrollees 
♦♦ per 1 ,000 discharges 
na Not applicable because cardiac catherization is a diagnostic procedure that is often followed by a surgical procedure 

-I- significant at p value < 0.01 

SOURCE: Data from the Health Care Financing Admini.stration's Bureau of Data Management and Strategy, 
Medicare Provider Analysis and Review files. 



Appendix IV 

Impact of the Medicare Fee Schedule on 
Access to Physician Services 



Prepared by: Janet B. Mitchell, Ph.D. 
Center for Health Economics Research 

April 1994 

Revised May 31, 1994 



Appendix IV 

Impact of the Medicare Fee Schedule on 
Access to Physician Services 



INTRODUCTION 



This appendix examines baseline measures of access using 1991 claims and presents 
some preliminary comparisons of 1991-1992. It focuses on those subgroups of the 
Medicare population who may be particularly vulnerable to any shifts in the supply of 
physician services. These subgroups include the follov^ng: 

Residents of health professional shortage areas, and of rural areas more 
generally . These residents may already be experiencing some difficulties 
in obtaining physician services because of the supply of medical personnel. 
Do payment changes resulting from MFS exacerbate problems that might 
already exist? 

Dual fMedicare-Medicaid) ehgibles and other poor elderly . Because these 
patients^may be less financially remunerative to physicians, the MFS may 
have exacerbated the problem. 

"Very old" and disabled beneficiaries . Because these enrollees may need 
disproportionately more physician services compared with relatively 
healthier Medicare enrollees, even small reductions in service could 
produce adverse outcomes. 

Black beneficiaries . For reasons that are not completely understood, 
black Medicare enrollees undergo many procedures at rates well below 
those of white enrollees. Is this utilization gap widened during the 
transition to MFS? 

We present three types of access measures: (1) outcomes; (2) utilization; and (3) 
financial impacts. Outcomes are measured as admissions for ambulatory care sensitive 
(ACS) conditions, or potentially avoidable hospitahzations. Utilization measures include 
rates of use for preventive services, visits, and high tech diagnostic and therapeutic 
procedures. Measures of financial impact include per enrollee spending for physician 
services, coinsurance, and extra bill amounts, as well as assignment rates. 



Appendix IV- 1 



METHODS 

Sample Design 

The major intent of this legislation was to provide more rational and equitable payment 
through the development of a budget neutral Medicare fee schedule. This led to a shift 
of Medicare payments from procedural services to evaluation and management services. 
It also led to a shift in Medicare payments from urban areas to rural areas. This 
inter-area variation provided us with a natural quasi-experimental design for evaluating 
MFS impacts on access to care. If physicians respond to payment reductions by 
providing fewer services, then areas with greater payment reductions should exhibit 
greater declines in utilization and worse outcomes, compared with areas experiencing 
smaller reductions. We categorized all geographic areas into six groups based on their 
expected 1992 payment change under MFS compared to the old system (see Technical 
Note A for further detail): 

1. 8 percent or greater reduction, 

2. Greater than or equal to a 5 percent reduction, but less than an 8 percent 
reduction, 

3. Greater than or equal to a 3 percent reduction, but less than a 5 percent 
reduction, 

4. Greater than or equal to a 1 percent reduction, but less than a 3 percent 
reduction, 

5. Between a 1 percent reduction (not inclusive) and a 2 percent increase 
(not inclusive), and 

6. 2 percent or greater increase. 

The first two categories represent areas with fairly substantial payment reductions, the 
third and fourth have more modest reductions, and areas in the final two categories 
experienced little change or even increases in payments. 

If the MFS has any adverse effects on access to care, however, these effects are most 
likely to be felt by those population subgroups who may be particularly vulnerable to 
any shifts in the supply of physician services. Potentially vulnerable beneficiaries are 
those with limited financial resources to pay coinsurance and extra billing amounts, 
those in areas with relatively few physicians, and those with extraordinary health care 
needs. We identified nine groups of such beneficiaries: 



Appendix IV-2 



Those residing in a rural health professional shortage area (HPSA); 

Those residing in an urban HPSA; 

Those residing in a rural poverty area; 

Those residing in an urban poverty area; 

Those jointly ehgible for Medicaid; 

Black beneficiaries; 

Those originally entitled to Medicare because of disability or ESRD; 

The "very old" (85 years and older); and 

Those residing in any rural area. 

All Medicare beneficiaries not meeting any of these criteria constituted a tenth group. 

Because many of these subgroups represent only a small proportion of the total 
Medicare population, changes in access for them could be masked using a simple 
random sample of beneficiaries. For this reason, we used a stratified random sampling 
design that ensured large numbers of vulnerable beneficiaries within each payment 
change category. The 1991 denominator file constituted the samphng frame. All 
Medicare enroUees were categorized by payment group category (based on their 
residence) and by vulnerable population group.^ 

Table IV- 1 displays the nine vulnerable subgroups as a percent of all Medicare 
beneficiaries (a beneficiary can fall into more than one category) as well as the percent 
of beneficiaries residing in each of the six payment change areas. From this table, it is 
obvious why a simple random sample design is insufficient. A relatively small 
proportion of Medicare beneficiaries reside in HPSAs or poverty areas, for example, 
and an even smaller number reside in those parts of the country experiencing major 
payment reductions. 

The stratified random sampling design that we employed ensured not only that we 
obtained adequate numbers of each of the potentially vulnerable subgroups, but also 
adequate number of each vulnerable subgroup living in each of the six payment change 



'A more detailed description of the sample design can be found in the technical notes. 

Appendix IV-3 



areas. Thus, samples of all ten groups of beneficiaries (the nine vulnerable subgroups, 
plus the tenth "all other" group) were drawn from each of the six payment change 
strata. The final 1991 sample consisted of 2,754,770 beneficiaries. A replacement 
sample of newly eligible (in 1992) beneficiaries was later added using the same 
sampling criteria. 

Data Sources 

The analysis in this appendix is based on three main data sources: (1) the denominator 
file; (2) MEDPAR claims for acute hospital stays; and (3) Part B claims. As discussed 
earlier, the denominator file was used to draw the sample; it also provided 
sociodemographic characteristics for each member of the sample. MEDPAR claims 
were used to construct hospital admission rates and surgical rates. Part B claims were 
used to create a wide range of physician utilization measures, as well as summary 
expenditure data. 

Measures and Statistical Tests 

We present three types of access measures: (1) outcomes; (2) utilization; and (3) 
financial impacts. Outcomes are measured as admission rates for ambulatory care 
sensitive (ACS) conditions.^ Admissions for ACS conditions are considered outcomes 
because these hospitalizations are potentially avoidable with adequate and timely 
outpatient care. If such admissions are higher for vulnerable populations than for 
comparison beneficiaries, this suggests that barriers to care may exist for those 
vulnerable subgroups. Billings and colleagues (1991) have developed a list of 24 ACS 
conditions applicable to adults based on principal diagnosis. Utilization measures 
include rates of use for preventive services, visits, and high-tech diagnostic tests and 
therapeutic procedures. Measures of financial impact include per enrollee spending for 
physician services, coinsurance, and extra bill amounts, as well as assignment rates. 

All rates were standardized for age and sex using the direct method. For comparisons 
of very old versus younger beneficiaries, the rates were standardized for sex only. 

T-tests were used to determine the statistical significance of differences across groups 
and over time. Because of the complex nature of the sample design, weighting and 
standard error adjustments were required. 



^ Some national rates for specific Ambulatory Care Sensitive conditions may vary from those 
obtained from 100 percent data due to sampling. 

Appendix IV-4 



RESULTS 

Outcome Measures of Access 

Table IV-2 displays admission rates for four ACS conditions, as well as total ACS 
admission rates, for each of the vulnerable population groups. More detailed, 
condition-specific, ACS tables can be found in the Technical Notes (Tables IV-B-1 
through B-4). Rates for each vulnerable population are contrasted with the appropriate 
comparison group; thus, residents of shortage areas are compared with those in non- 
shortage areas, black with white beneficiaries, etc. 

Total ACS admission rates were significantly higher for a]! of the vulnerable groups, 
except residents of rural shortage areas. The absolute magnitude of the differences is 
striking. Beneficiaries living in poor urban areas were almost 50 percent more likely to 
be hospitalized with an ACS condition, compared with those in nonpoor areas, for 
example, and black beneficiaries 40 percent more likely than whites. Very old and 
disabled beneficiaries were admitted with ACS conditions at twice the rate of their 
younger, non-disabled colleagues. At least some of this differential may be due to their 
poorer health status; even with the best of outpatient care, these beneficiaries may be 
at increased risk of hospitalization. To the extent that some beneficiaries become 
eligible for Medicaid under medically needy provisions, then poor health status could be 
a partial factor in their disproportionately high rates. Poverty and residence in a 
shortage area are other, probably more important, factors. Admission rates for 
individual ACS conditions generally follow the same patterns as overall ACS admissions 
rates. 

One explanation for higher ACS rates among these population subgroups might be 
higher hospital admission rates generally. The disabled and very old, for example, are 
more likely to be hospitalized, simply because of their poorer health status. Practice 
patterns, treatment preferences, or other factors might explain higher rates for other 
subgroups. In order to examine this, we calculated total admission rates for non-ACS 
conditions and compared them across groups (not shown). Non-ACS admission rates 
were indeed higher for all but one of the vulnerable subgroups, although the differential 
was far smaller than that for ACS admission rates,^ 

We calculated adjusted relative rates for ACS admissions, following the approach of 
Weissman et ai, 1992. While the adjustment did narrow the differential between 
groups, a substantial "access gap" remained. The ratio of black to white ACS admission 



^ The one exception was rural shortage areas where non-ACS admission rates were significantly 
lower than in non-shortage areas. However, there were no differences in ACS admission rates between 
rural shortage and non-shortage areas (see Table IV-2). 

Appendix IV-5 



rates, for example, is 1.41 (84.2/59.8 from Table IV-2). Adjusting by the ratio of black 
to white non -ACS admission rates lowered this ratio to 1.34. Similarly, the urban poor 
to nonpoor ratio declined from 1.47 to 1.40 , still a substantial difference in ACS 
admission rates. 

Utilization Measures of Access 

Table IV-3 presents rates of visits and consultations. Although five different kind of 
visits are shown, our primary focus is on outpatient and emergency room (ER) visits. 
These ambulatory visits are the utilization measures most directly associated with our 
outcome measure (ACS admissions). Outpatient visits include visits in the physician's 
office as well as in an outpatient department or other ambulatory facihty. 

Residents of both urban and rural shortage areas, those living in poor rural areas, black 
beneficiaries, and rural residents generally all receive statistically significant fewer 
outpatient visits than their respective comparison group. This may well be a factor in 
their higher rate of ACS admissions. (Lower outpatient visit rates for the "very old" 
may simply be due to their higher rate of nursing home placement; note the large 
number of nursing home visits per beneficiary in this group.) 

Surprisingly, residents of poor urban areas make as many outpatient visits as those in 
nonpoor areas. Medicaid-eligible and disabled beneficiaries have significantly more 
ambulatory physician visits (and more ACS admissions) than other beneficiaries, 
possibly in part because of their poorer health status. While high ACS admission rates 
for these beneficiaries might seem paradoxical, given their relatively large numbers of 
outpatient visits, ambulatory care must be both timely and adequate in order to avoid 
unnecessary hospitalizations. Even though Medicaid-eligible and disabled Medicare 
beneficiaries receive more ambulatory care than their comparison groups, it may be that 
the ambulatory care differential should be even greater , given their generally known 
poorer health status. Moreover, Medicaid-eligible beneficiaries and those living in poor 
urban areas may be receiving a disproportionate share of those visits in hospital 
outpatient departments, rather than in private physicians' offices. These settings may 
not provide continuity of care and, particularly in public facilities, may fail to provide all 
needed services." All vulnerable groups make significantly more trips to the ER, except 



'' In a recent study, the Center for Health Economics Research (CHER) (1993) found that the 
percent of late stage diagnoses among poor women and black women with cervical cancer actually 
increased significantly over the 1980s, even though Pap test use remained constant or improved over the 
same time period. Since poor women and black women were significantly more likely to receive their 
Pap tests in a hospital or other clinic setting, quality of care problems in these facilities may be one 
explanation. In the late 1980s, for example, New York City laboratories were overwhelmed with the 
number of tests they received, and simply failed to read as many as 3,000 Pap tests (Fahs and Garibaldi, 
1992). 

Appendix IV-6 



for those in poor rural areas and rural areas generally. The absolute number of such 
visits is relatively small for aU groups, however. 

Medicare currently covers four preventive services: screening mammography, Pap tests, 
and pneumococcal pneumonia vaccinations, and influenza vaccinations. Table IV-4 
presents utilization rates of three of these services. Mammography rates are 
significantly lower for all of the vulnerable subgroups. The utilization gap is 
considerable, with poor rural women, black women, and Medicaid-eligible women only 
55-65 percent as likely to be screened. The gap in Pap test use is about as large, with 
women in all of the vulnerable subgroups (except those in rural shortage areas and 
rural areas generally) significantly less likely to be tested. These two services are 
relatively recent Medicare benefits (1/91 and 7/90, respectively), and neither test is 
recommended annually. While this might explain low rates of use for female Medicare 
beneficiaries in general, it cannot explain the systematically lower rates for poor versus 
nonpoor women, black versus white women, etc. 

Immunization rates for pneumococcal pneumonia are also significantly lower for all of 
the vulnerable subgroups, except for those beneficiaries living in shortage areas or in 
rural areas generally. These differences are difficult to evaluate, as the reliability of 
pneumococcal pneumonia vaccine reporting in claims data is unclear. A large number 
of disabled and elderly beneficiaries may receive their vaccinations in public health 
clinics or other settings in which no Part B bills are submitted to Medicare. Moreover, 
unlike other preventive services which are recommended on a regular basis, 
pneumococcal pneumonia immunization need only be performed once in a lifetime. 
Thus, an unknown number of beneficiaries may have been vaccinated prior to 1991. 

The MFS lowered payments for many cardiac procedures. This is an area of particular 
concern, as certain groups of Medicare beneficiaries, such as blacks, historically have 
had below-average utilization rates for these procedures. Table IV-5 presents utilization 
rates for two diagnostic cardiac tests (echocardiography and cardiac catheterization) and 
three cardiac procedures (PTCA, CABG surgery, and permanent pacemaker insertion). 
All of the vulnerable subgroups show significantly higher rates of use for 
echocardiography, except for rural residents who are significantly less likely to receive 
this ultrasound test. 

Beneficiaries living in shortage areas or poor areas, black beneficiaries, those jointly 
eligible for Medicaid, and the very old are significantly less likely to receive cardiac 
catheterization, PTCA, or CABG surgery. The differences in use are considerable: 
Residents of poor urban areas are only 60 percent as likely to undergo bypass surgery 
compared with comparable residents of nonpoor areas, for example, and black 
beneficiaries undergo CABG surgery at only one-third the rate of whites. Black 
beneficiaries were also less likely to have a pacemaker implanted. The lower rates 



Appendix IV-7 



observed for the very old may reflect less aggressive treatment patterns for a population 
subgroup more likely to be frail. 

Disabled beneficiaries receive all of the cardiac tests and procedures at significantly 
higher rates; this may reflect a cardiac disability or a disability, like renal disease, that 
has cardiac complications. Despite lower rates of echocardiography by rural residents, 
there were no urban-rural differences for any of the other procedures shown on 
Table IV-5. 

We also examined utilization rates for a number of diagnostic tests and procedures; 
Table IV-6 presents two selected "high-tech" radiologic tests (head computerized (axial) 
tomography (CT) and brain magnetic resonance imaging (MRI) scans) and three 
gastrointestinal (GI) endoscopies (upper GI, sigmoidoscopy, and colonoscopy). Rates of 
use for head CT scans were lower in rural shortage areas and in rural areas generally, 
but were otherwise significantly higher for vulnerable populations. Higher utilization 
rates for black beneficiaries and for the "very old" are consistent with their greater 
incidence of cerebrovascular disease. Surprisingly, however, these same groups of 
beneficiaries are significantly less likely to receive MRI scans of the brain. MRI rates 
are also lower for all of the other vulnerable subgroups, except for Medicaid-eligible 
and disabled beneficiaries. 

Except for those living in rural areas, vulnerable beneficiaries are significantly more 
likely to undergo upper GI endoscopy. A very different picture emerges for 
endoscopies of the lower GI tract, however. Rates of use for both sigmoidoscopy and 
colonoscopy are significantly lower for all of the vulnerable subgroups. 

The MFS also lowered payments for many orthopedic procedures (Table IV-7). Most 
of the vulnerable subgroups are less likely to receive any of the three procedures 
shown: arthroscopy, total hip replacement, and total knee replacement. For some 
groups, the use differential is considerable; black beneficiaries, Medicaid-eligibles, and 
those living in poor areas are far less likely to undergo knee replacement, for example. 
Despite large absolute differences in hip replacement use, these rates are not 
statistically significant because of unusually large standard errors. We are exploring 
possible data coding problems that might account for this. 

Because of the potential data coding problems associated with our measurement of hip 
replacement from Part B data, we also present a measure of joint replacement 
calculated from Part A data. This particular measure was defined by Billings (1991) 
and colleagues as a referral-sensitive surgery, and includes both hip and knee 
replacements. We again observe large gaps in use, especially for residents of urban 
shortage areas and poor areas, and for black beneficiaries. 



Appendix IV-8 



We also examined differences in a number of other surgical procedures, including: 
carotid endarterectomy, colectomy, cholecystectomy (both by the traditional and 
laparoscopic approaches), transurethral resection of the prostate, hysterectomy, and 
cataract surgery. The tables can be found in the Technical Notes (Tables IV-B-5 
through B-8). Highlights include: 

Lower rates for many procedures for the vulnerable subgroups, but 

Higher rates of cholecystectomy for those living in poor rural areas. 

Financial Liability 

There are two sources of patient financial liability: coinsurance and extra billing 
amounts. Both sources are shown in Table IV-8, along with assignment rates. All 
variables are expressed at the beneficiary level; monetary variables have been adjusted 
for geographic cost-of-living differences. A similar table using nominal dollars can be 
found in the Technical Notes (Table IV-B-9). 

Physicians appear more willing to accept assignment on patients in vulnerable 
population groups and, as a result, these beneficiaries are hable for significantly lower 
extra bill amounts. However, these higher rates of assignment are very likely influenced 
by the fact that assignment is mandatory for joint Medicaid eligibles, and a 
disproportionate number of such eligibles are found among the vulnerable subgroups. 
Rural residents are an exception, where assignment rates are slightly lower and extra 
bill amounts correspondingly higher. 

Even after adjustment for cost-of-living differences, some vulnerable beneficiaries are 
responsible for higher coinsurance amounts, including residents of poor urban areas, 
Medicaid-eligibles, disabled, and very old beneficiaries. Higher coinsurance amounts 
reflect a combination of a greater absolute level of use, a more complex mix of 
services, and higher fees. 

Changes in the First Year of the Medicare Fee Schedule 

Using Part A claims data, we examined 1991-1992 changes in four access measures: 
ACS admission rates; 
CABG surgery rates; 
Rates of hip and knee replacements; and 
PTCA rates. 

Appendix IV-9 



In order to detect any first-year effects of the Medicare Fee Schedule, we calculated 
percent changes separately by size of the MFS payment change. Of course, two points 
in time, do not represent a trend; these results must be considered preliminary. 

Table IV-9 presents the percent changes in ACS admission rates for each vulnerable 
population subgroup within each of the six MFS payment change categories. There was 
little significant change from 1991 to 1992, and no strong evidence of association with 
the MFS. There was a slight tendency for ACS admissions to increase in areas with 
large payment reductions and to decrease in areas experiencing no change or even 
payment increases under the MFS. Note the significant increases for blacks in 
category 1, for the very old in both categories 1 and 4, and for the poor in category 2, 
for example.^ Similarly, note the significant decreases among poor rural enrollees in 
category 5 and among poor urban and very old enrollees in category 6. At this point, 
these patterns are merely suggestive and should continue to be monitored. 

Although changes in CABG surgery rates overall were not significant, there were some 
dramatic changes for some vulnerable groups (Table IV-10). None of these changes 
appear to be correlated with payment changes under the MFS, however. In category 2, 
for example, CABG rates increased in shortage areas but declined among poor 
beneficiaries. 

Rates of hip and knee replacement generally grew from 1991 to 1992 (Table IV-11), 
especially in areas doing better under the MFS. Joint replacements increased 14-15 
percent in categories 5 and 6, although these increases were not always shared by the 
vulnerable subgroups. In areas with little payment change under MFS (category 5), 
rates of hip and knee surgery increased for many vulnerable beneficiaries, for example, 
but not for blacks or residents of poverty areas. Changes in areas with large payment 
reductions were somewhat mixed, with some vulnerable groups enjoying better access to 
joint replacement surgery and others less. 

PTCA rates also generally grew from 1991 to 1992, with dramatic rates of increase for 
some vulnerable subgroups. This growth appears to have occurred, regardless of the 
size of the MFS payment change, although the marked reduction in PTCA among rural 
residents in areas experiencing very large payment reductions (category 1) is troubling 
(Table IV-12). 



^ We ignore the declines for residents in rural shortage areas, since this was the only vulnerable 
subgroup not to have significantly higher ACS admission rates in 1991. 



Appendix IV-10 



CONCLUSION 

This report highlights substantial utilization differences between the vulnerable 
population subgroups studied and their comparison groups. ACS admission rates were 
significantly higher for the vulnerable groups. Utilization rates for many physician 
services were significantly lower for some vulnerable populations as well, particularly the 
utilization of preventive services and the cardiac tests and procedures. Beneficiaries 
living in manpower shortage areas, those living in rural areas, and black beneficiaries 
also received significantly fewer outpatient visits. Taken together, these facts suggest 
that these vulnerable beneficiaries may face barriers to receiving outpatient care or the 
care they do receive may not be adequate. 

Data for four of our measures from 1991-92 suggest that access has neither worsened 
nor improved during the first year of MFS implementation. At this point in time, these 
data must be considered very preliminary but deserve close monitoring in the future. 



Appendix IV- 11 



REFERENCES 

Billings, John. Ambulatory Care Access Project . United Hospital Fund of New York, 
1991. 

Center for Health Economics Research (CHER). Access to Health Care. Key 
Indicators for Policy , Princeton, N.J.: The Robert Wood Johnson Foundation, 
November 1993. 

Fahs, Marianne C. and Karen Garibaldi, Relationships among Insurance Coverage. 
Access to Services and Health Outcomes: Case Study of Cervical Cancer and African- 
American Women . Report prepared for the Office of Technology Assessment, U.S. 
Congress, Washington D.C., April 1992. 

Weissman, Joel S., Constantine Gatsonis, and Arnold M. Epstein, "Rates of Avoidable 
Hospitalization by Insurance Status in Massachusetts and Maryland," JAMA , 268:2388- 
2394, November 4, 1992. 



Appendix IV-12 



TABLE IV- 1 

SAMPLE DESCRIPTION 



Vulnerable Subgroup 

Urban Shortage Area 
Rural Shortage Area 

Urban Poverty Area 
Rural Poverty Area 

Black 

Medlcald-Eligible 

Disabled (original reason for eligibility) 

Very Old (85+) 

Any Rural Area 



Percent of Beneficiaries 

3.5 % 
2.1 

6.2 
1.7 

8.3 
12.1 
15.0 

9.1 
28.2 



Medicare Payment Change Category 



A 



V 



Reduction 1 
2 
3 
4 
5 
Increase 6 



Percent of Beneficiariesfa) 

4.1 % 
11.1 
23.0 
34.7 
18.3 

8.8 



(a) May not sum to 100% due to rounding. 
Source: Medicare 1991 denominator file. 



TABLE IV- 2 

AMBULATORY CARE SENSITIVE (ACS) ADMISSION RATES FOR VULNERABLE POPULATION 
GROUPS, 1 991 (age-sex adjusted admissions per 1 .000 benefictaries) 



Bacterial 
Pneumonia 



Asthma 



Congestive 
Heart 
Failure 



Dial}etesw/ 
Complications fa) TOTALfbl 



Siiortage Area 



All Shortage Combined 11.1 

Urtjan 10.3 

Rural 12.3 

Non 10.4 



3.8 
4.7 
2.4 
2.7 



19.1 
21.5 
15.3 
15.7 



4.0 
4.7 
3.0 
Z8 



71.8 
77.7 
62.5 
60.8 



Poverty Area 



All Poor Combined 

Urtan 

Rural 
Non Poor 



11.6 
10.5 
15.6 
10.3 



4.1 
4.2 
3.7 
2.7 



21.2 
21.7 
19.6 
15.5 



4.8 
4.9 
4.6 
2.7 



79.1 " 
88.2" 
76.6" 
59.9 



Race 



Black 
White 



9.7 

10.6 



4.6 
26 



25.3 
15.2 



6.8 
2.5 



84.2 
59.8 



Medicaid Eligible 



Yes 
No 



23.4 
9.0 



6.0 
2.4 



326 
14.1 



6.5 
24 



136.1 
53.3 



Disabled 



Yes 
No 



16.4 " 


5.9" 


27.2" 


6.1 " 


110.7 


9.8 


24 


14.6 


22 


55.8 



Age 



85+ Years 


30.0" 


2.4" 


39.2" 


2.3" 


130.3" 


Less than 85 


9.9 


28 


15.3 


2.9 


59.5 


Residence 












Rural 


13.0" 


28 


15.7 


3.0 


68.0" 


Urban 


9.4 


2.7 


16.0 


2.8 


58.8 


ALL BENEFICIARIES 


10.4 


2.7 


15.9 


2.9 


61.4 



"Significantly different from comparison group at 0.05 level. 
"Significantly different from comparison group at 0.01 level. 

(a) Includes ketoacidosis, coma, and all otiier comptlcations. 

(b) Includes all ACS conditions, not just those shown here. 



Note: Rates for each vulnerable group are contrasted with the appropriate comparison group. 
Source: Part A claims and denominator file for a sample of Medicare beneficiaries, 1991. 



TABLE IV- 3 

VISITS AND CONSULTATIONS FOR VULNERABLE POPULATION GROUPS, 1991 
(age-sex adjusted visits per beneficiary) 



Outpatient 

Visits ER Visits 



Home Hospital 
Visits Visits 



Nursing 
Home 
Visits Consultations 



Siiortaqe Areas 



All Shortage Combined 

Urban 

Rural 
Non-Shortage 



4.72- 


0.38- 


0.03 


2.61 - 


0.30 


0.41 


4.91 - 


0.42- 


0.04- 


3.08- 


0.34- 


0.49 


4.43- 


0.32- 


0.02- 


1.87- 


0.25- 


0.28 


5.12 


0.31 


0.03 


2.42 


0.31 


0.40 



Poor Areas 



Ail Poor Combined 

Urban 

Rural 
Non Poor 



5.07* 


0.41 - 


0.06- 


3.06- 


0.38- 


0.48 


5.12 


0.42- 


0.07- 


3.21 - 


0.41 - 


0.54 


4.89- 


0.37 


0.01 


2.49 


0.26 


0.27 


5.10 


0.31 


0.03 


2.38 


0.31 


0.40 



Race 



Black 
White 



4.67 - 


0.47- 


0.03* 


3.23- 


0.37- 


0.45 


5.21 


0.31 


0.03 


2.41 


0.32 


0.41 



Medicaid Eligible 



Yes 
No 



5.71 - 


0.69- 


0.07- 


4.60- 


1.51 - 


0.59 


5.03 


0.28 


0.03 


2.20 


0.18 


0.38 



Disabled 



Yes 
No 



5.43- 


0.57- 


0.05- 


3.94 - 


0.55- 


0.56 


5.06 


0.29 


0.03 


2.26 


0.29 


0.39 



Age 



85+ Years 


4.26- 


0.53- 


0.17- 


4.36- 


2.26- 


0.51 - 


Less than 85 


5.12 


0.31 


0.03 


2.38 


0.26 


0.40 


Area of Residence 














Rural 


4.72- 


0.32 


0.02- 


2.08- 


0.28- 


0.29- 


Urban 


5.25 


0.32 


0.04 


2.57 


0.32 


0.45 


ALL BENEFICIARIES 


5.10 


0.32 


0.03 


2.43 


0.31 


0.40 



'Significantly different from comparison group at the 0.05 level. 

**Significantiy different from comparison group at the 0.01 level. 

Note: Rates for each vulnerable group are contrasted with ttie appropriate comparison group. 

Source: Part B claims and denominator file for a sample of Medicare t>eneficiaries, 1991 . 



TABLE TV- 4 

PREVENTIVE SERVICE USE FOR VULNERABLE POPULATION GROUPS. 1991 
(age-sex adjusted services per 1 ,000 beneficiaries) 





MammoaraDhv (a) 


PaoTestra) 


Pneumococcal 

Pneumonia 

immunization 


Shortaae Areas 








All Shortage Combined 

Urban 

Rural 
Non-Shortage 


240.1 *• 

231.2 •* 
254.9- 
281.3 


149.5 - 
133.0 - 
177.0 
199.7 


54.28- 
61.14 - 
43.33 
38.05 


Poor Areas 








All Poor Combined 

Urban 

Rural 
Non Poor 


215.3 - 
221.4- 
191.6 - 
284.3 


145.3 - 
138.1 - 

173.4 * 
201.3 


19.51 - 
18.96 - 
21.55 - 
40.49 


Race 








Black 
White 


195.0 - 
293.0 


156.7 - 
205.2 


27.46 - 
40.74 


Medicaid Eliaible 








Yes 
No 


156.6 - 
294.9 


110.5- 
208.2 


20.91 - 
40.89 


Disabled 








Yes 
No 


225.4- 
283.1 


166.9 - 
199.3 


29.64 - 
39.99 



Age 



85+ Years 


64.1 - 


50.4 


Less than 85 


287.2 


202.6 


Area of Residence 






Rural 


252.0 - 


213.1 


Urban 


289.3 


191.0 


ALL BENEFICIARIES 


278.8 


197.2 



23.68 
39.35 



34.71 
40.56 

38.91 



*Significantly different from comparison group at the 0.05 level. 

**Signrficantiy different from comparison group at the 0.01 level. 

(a)Age-adjusted for female enrollees only. 

Note: Rates for each vulnerable group are contrasted with the appropriate comparison group. 



Source: Part B claims and denominator file for a sample of Medicare beneficiaries, 1991 . 



TABLE 



IV- 5 



UTILIZATION OF CARDIAC TESTS AND PROCEDURES FOR VULNERABLE POPULATION 
GROUPS, 1991 (age-sex adjusted services per 1 ,CX)0 beneficiaries) 







Cardiac 






Pacemalcer 




EchocardioaraDhv 


Catheterization 


PICA 


CABG 


Insertion 


Shortaae Areas 












All Shortage Combined 


164.20- 


19.31 


3.37- 


4.37- 


Z34 


Urban 


188.07 - 


19.04- 


Z96- 


3.99- 


2.32 


Rural 


126.10 - 


19.75 - 


4.04- 


4.99 


238 


Non-Shortage 


155.57 


2Z19 


4.86 


5.40 


2.40 


Poor Areas 












All Poor Combined 


191.05** 


17.30- 


3.20- 


3.48- 


Z50 


Urban 


206.38** 


16.28- 


2.94- 


3.24- 


Z50 


Rural 


134.63- 


21.05- 


4.13- 


4.32- 


Z48 


Non Poor 


153.23 


22.42 


4.91 


5.49 


Z39 


Race 












Black 


186.42 - 


15.44- 


2.36- 


2.05- 


Z19* 


White 


155.79 


23.00 


5.10 


5.73 


Z46 


Medicaid Eliqible 












Yes 


210.91 - 


20.06- 


3.75- 


3.39- 


3.11 - 


No 


150.08 


22.25 


4.90 


5.55 


Z32 


Disabled 












Yes 


202.04- 


30.99- 


5.59- 


7.51 - 


3.05- 


No 


150.80 


21.02 


4.69 


5.09 


Z32 



Age 



85+ Years 


174.41 - 


3.01 - 


0.79- 


0.41 - 


4.91 - 


Less than 85 


155.53 


2Z56 


4.89 


5.48 


Z33 


Area of Residence 












Rural 


129.84- 


21.26 


4.51 


5.12 


Z33 


Urban 


166.20 


22.34 


4.89 


5.42 


Z43 


ALL BENEFICIARIES 


155.95 


22.04 


4.78 


5.34 


Z40 



•Significantly diffefent from comparison group at the 0.05 level. 
"Significantly different from comparison group at the 0.01 level. 
Note: Rates for each vulnerable group are contrasted with the appropriate comparison group. 



Source: Part B claims and denominator file for a sample of Medicare benefkaaries, 1991. 



TABLE IV- 6 

UTILIZATION OF DIAGNOSTIC TESTS AND PROCEDURES FOR VULNERABLE POPULATION GROUPS. 1991 
(age-sex adjusted tests per 1 ,000 beneficiaries) 



HeadCT 



Brain MRI 



Upper Gl 
Endoscopy Sigmoidoscopy Colonoscopy 



Shortaae Areas 












All Shortage Combined 


70.6- 


13.2- 


36.2 


32.6- 


33.5 


Urban 


79.4- 


14.2- 


39.2- 


31.3- 


35.0 


Rural 


56.6- 


11.5- 


30.3- 


34.5- 


31.0 


Non-Shortage 


67.0 


16.0 


36.0 


45.4 


39.1 


Poor Areas 












Ail Poor Combined 


77.6- 


13.9- 


38.1 - 


29.9- 


34.9 


Urban 


80.5- 


14.7- 


38.6- 


30.7- 


35.8 


Rural 


67.3 


11.0- 


36.2 


26.8- 


31.6 


Non Poor 


66.4 


16.0 


35.9 


45.9 


39.1 



Race 



Black 
White 



88.5- 


12.8- 


40.8- 


27.7- 


33.8 


66.9 


16.4 


36.3 


47.0 


39.9 



Medicaid Eligible 



Yes 
No 



113.2- 


16.8* 


56.2- 


26.3- 


34.1 


62.2 


15.7 


33.8 


46.7 


39.3 



Disabled 



Yes 
No 



89.2- 


18.8- 


48.9- 


32.1 - 


36.8 


64.7 


15.5 


34.6 


46.2 


39.0 



Age 



85+ Years 


108.4- 


9.0- 


42.7- 


27.4- 


26.3 


Less than 85 


66.1 


16.0 


35.8 


45.2 


39.1 


Area of Residence 












Rural 


61.9- 


1Z6- 


33.3- 


36.7- 


33.7 


Urban 


69.3 


17.1 


37.1 


47.9 


40.7 


ALL BENEFICIARIES 


67.2 


15.8 


36.0 


44.7 


38.7 



•Significantly different from comparison group at the 0.05 level. 
"•Significantly different from comparison group at the 0.01 level. 
Note: Rates for each vulnerat>le group are contrasted with the appropriate comparison group. 



Source: Part B dainns and denominator file for a sample of Medicare beneficiaries, 1991. 



TABLE IV- 7 

UTILIZATION OF ORTHOPEDIC PROCEDURES FOR NAJLNERABLE POPULATION GROUPS, 1991 
(age-sex adjusted procedures per 1 ,000 beneficiaries) 







Total Hip 


Total Knee 


Hip and Knee 




Arthroscopy Replacement (a) 


Replacement (a) 


Replacements (b) 


Shortaqe Areas 










All Shortage Combined 


2.84- 


Z36 


3.68 


6.17- 


Urban 


2.63- 


1.91 


3.05- 


5.14- 


Rural 


3.16- 


3.07 


4.70 


7.81 - 


Non-Shortage 


3.67 


4.62 


3.99 


6.99 


Poor Areas 










All Poor Combined 


2.21 - 


1.62 


2.68- 


4.55- 


Urban 


2.10- 


1.53 


2.48- 


4.29- 


Rural 


2.59- 


1.97 


3.43- 


5.49- 


Non Poor 


3.74 


4.73 


4.07 


7.14 


Race 










Black 


1.56- 


1.54 


2.93- 


4.46- 


White 


3.85 


4.96 


4.15 


7.23 


Medicaid Ellalble 










Yes 


2.48- 


Z23 


3.30- 


5.76- 


No 


3.75 


4.75 


4.04 


7.07 


Disabled 










Yes 


3.98 


3.07 


4.15 


7.40- 


No 


3.58 


4.66 


3.95 


6.89 



Age 



85+ Years 


0.56- 


2.58 


1.50- 


4.09 


Less than 85 


3.71 


4.55 


4.04 


7.02 


Area of Residence 










Rural 


3.25 


2.97 


4.49- 


7.65 


Urban 


3.77 


5.09 


3.77 


6.67 


ALL BENEFICIARIES 


3.62 


4.49 


3.97 


6.95 



•Signrficantty different from comparison group at the 0.05 level. 

"Significantly different from comparison group at the 0.01 level. 

(a)Defined by Part B surgeons' t>ills. 

(b)Defined t>y Part A hospital bills. 

Note: Rates for each vulnerable group are contrasted with the appropriate comparison group. 



Source: Part A and Part B claims and denominator file for a sample of Medicare bendicianes, 1991. 



TABLE IV- 8 

DEFLATED PHYSICIAN SPENDING AND OUT-OF-POCKET LIABILITY. AND ASSIGNMENT RATES FOR 
VULNERABLE POPULATION GROUPS, 1991 (age-sex adjusted per beneficlary)(a) 



Age 



Total 




Extra 


Total Beneficiary 




Parts 


Coinsurance 


Billing 


Liability as 




Physician 


Liability 


Liability 


Percent of 


Assignment 


Spendina 


iSL 


iSl 


Spending 


Rate 



Shortage Areas 














All Shortage Combined 


$956.80 ** 


$191.35 ** 


$24.88 ** 


23.8 ' 


%** 


66.8 % 


Urban 


1,024.63 


204.92 


16.67 ** 


22.7 


** 


70.4 


Rural 


848.48 ** 


169.69 ** 


37.99 ** 


25.7 


** 


64.9 


Non-Shortage 


1,015.98 


203.19 


36.70 


25.0 




65.0 


Poor Areas 














All Poor Combined 


1,013.29 


202.65 


16.21 •* 


22.6 


** 


71.5 


Urban 


1,036.71 *• 


207.34 ** 


15.22 •* 


22.4 


** 


71.8 


Rural 


927.09 ** 


185.41 ** 


19.88 ** 


23.4 


** 


70.4 


Non Poor 


1,012.74 


202.54 


37.66 


25.2 




64.6 


Race 














Black 


977.25 ** 


195.45 ** 


11.50** 


22.2 


** 


72.3 


White 


1,032.79 


206.55 


43.42 


25.3 




65.0 


Medicaid Eligible 














Yes 


1,301.13 *• 


260.22 *• 


5.91 ** 


20.6 


■** 


88.2 ' 


No 


981.48 


196.29 


39.34 


25.5 




62.6 


Disabled 














Yes 


1,223.68 ** 


244.73 ** 


27.66 ** 


23.2 


** 


71.7 ' 


No 


988.77 


197.75 


37.02 


25.2 




64.4 



85+ Years 


1,052.17 •* 


210.43 ** 


30.79 ** 


24.1 


** 


76.7 


*«■ 


Less than 85 


1,011.69 


202.33 


36.21 


25.0 




68.5 




Area of Residence 
















Rural 


906.51 ** 


181.30 ** 


39.40 ** 


25.9 


** 


65.5 


** 


Urban 


1.053.97 


210.79 


34.77 


24.6 




69.9 




ALL BENEFICIARIES 


1,012.39 


202.47 


36.08 


25.0 




68.7 





•Significantly different from comparison group at the 0.05 level. 

**Significantly different from comparison group at the 0.01 level. 

(a)AII dollars have been adjusted for geographic differences in cost-of-living. 

Note: Rates for each vulnerable group are contrasted with the appropriate comparison group. 



Source: Part B claims and denominator file for a sample of Medicare beneficiaries, 1 991 . 



I 



TABLE IV- 9 

1991-1992 PERCENT CHANGES IN TOTAL AMBULATORY CARE SENSITIVE ADMISSION RATES BY MFS PAYMENT CHANGE 
AND VULNERABLE POPULATION GROUPS (age and sex adjusted) 



MFS PAYMENT CHANGE 



Shortage Area 



Poverty Area 



Race 



Medicaid Eligible 



Disabled 



Reduction -^ 



Increase 

6 



All Shortage Combined 

Urban 

Rural 
Non-Shortage 



4.8 % 

4.9 
-0.4 
-3.1 



-2.0% 
-0.7 
-7.0" 
0.3 



-0.6 
0.3 
-7.5 
0.5 



3.3% 
6.3 
-2.1 
-0.2 



4.7 % 
Z6 
5.9 
Z1 



-2.3% 

-1.6 
-2.7 
-0.1 



All Poor Combined 

PoorUrtsan 

Poor Rural 
Non Poor 



21 
Z2 
2.0 
-3.2 



4.7 

4.0 

11.1 

-0.1 



-0.3 
0.1 
-Z8 
0.6 



2.9 
2.6 
4.0 
-0.2 



•0.8 
2.7 

-5.2 
2.5 



1.4 

-5.5 
3.1 
-0.3 



Black 
White 



5.4 
-3.7 



-1.7 
-0.5 



1.2 
0.7 



4.0 
-0.2 



Z4 
2.1 



1.7 
-0.2 



Yes 

No 



-3.0 
-2.7 



-1.6 
0.3 



0.4 
0.0 



1.2 
-0.6 



0.9 
2.2 



1.1 
-1.4 



Yes 
No 



1.2 


-1.2 


1.1 


3.4 


3.7 


0.4 


-3.6 


0.4 


0.2 


-0.8 


1.8 


-0.5 



Age 



85+ Years 


4.7" 


-1.5 


-Z7 


4.9" 


1.2 


-1.9* 


Less than 85 


-3.4 


0.2 


0.5 


-0.4 


2.3 


-0.1 


Residence 














Rural 


4.1 


2.0 


-3.7 


2.5 


1.7 


0.2 


Urban 


-3.1 


-0.1 


1.4 


-0.8 


Z8 


-1.2 


ALL BENEFICIARIES 


-2.9 


0.1 


0.4 


0.0 


Z3 


-0.1 



•Significantly different at the 0.05 level. 
—Significantly different at the 0.01 level. 
Note: All statistical tests refer to the 1991-1992 percent change in rates for each group. 



Source: Part A daims and denominator file for a sample of Medicare beneficiaries. 



TABLE IV- 10 

1991-1992 PERCENT CHANGES IN ADMISSION RATES FOR CABG SURGERY BY MFS PAYMENT CHANGE 
AND VULNERABLE POPULATION GROUPS (age and sex adjusted) 



Reduction-^ 



MFS PAYMENT CHANGE 



Increase 

6 



Shortage Area 



All Shortage Combined 

Uitan 

Rural 
Non-Shortage 



-8.2% 
-11.4 
(a)-* 
-6.4 



17.2% - 

17.0 • 

17.6 * 
12.1 



-2.2 
-4.2 
8.2 
5.9 



3.4% 
10.0 
-5.8 
10.3 



Z0% 
5.9 
0.5 
3.5 



1Z3% 
28.0 

6.4 

5.6 



Poverty Area 



All Poor 
Poor Urtjan 
Poor Rural 

Non Poor 



-3.5 


-12.6 * 


-6.4 


5.6 


0.1 


13.5 


-3.3 


-14.0 • 


-5.8 


7.3 


6.4 


16.6 


-27.6 


0.5 


-9.5 


-2.6 


-5.7 


12.6 


-6.6 


13.0 


6.5 


10.0 


3.5 


5.3 



Race 



Black 
White 



4.6 
-8.0 



14.2 
11.4 



8.7 
5.0 



19.0 
9.0 



6.9 

3.5 



11.3 
4.8 



Medicaid Eligible 



Yes 
No 



8.0 
-7.9 



5.9 
12.8 



Z8 
5.9 



3.3 
10.4 



11.2 
3.1 



1.6 
6.4 



Disabled 



Yes 
No 



■17.9 ** 


10.0 


6.8 


0.1 


-4.4 


6.4 


-4.5 


1Z5 


5.3 


11.4 


4.7 


5.6 



Age 



85+ Years 


-3.4 


69.2" 


6.2 


53.2 


17.1 


67.4 


Less than 85 


-6.4 


1Z2 


5.6 


9.9 


3.5 


5.8 


Residence 




' 










Rural 


21.1 


3.4 


6.7 


11.3 


3.6 


4.7 


Urban 


-7.1 


13.6 


5.3 


9.5 


3.3 


8.6 


ALL BENEFICIARIES 


-6.4 


12.2 


5.5 


9.9 


3.4 


5.8 



"Significantly different at the 0.05 level. 

•"Significantly different at the 0.01 level. 

(3)Percent change could not be calculated, as the 1991 rate was 0. 

Note: All statistical tests refer to the 1991 -1 992 percent change In rates for each group. 



Source: Part A ciaims and denominator file for a sample of Medicare t>eneficiaries. 



TABLE IV- 11 

1991 - 1992 PERCENT CHANGES IN ADMISSION RATES FOR HIP AND KNEE REPLACEMENT SURGERY BY MPS PAYMENT CHANGE 
AND VULNERABLE POPULATION GROUPS (age and sex adjusted) 



Shortage Area 

All Shortage 

Urtian 

Rural 
Non-Shortage 



MPS PAYMENT CHANGE 











1^ 


Increase 

6 


1 


2 


3 


4 


5 


-0.2% 


5.8% 


5.9 


2.2% 


24.6 % " 


3.8% 


-1.2 


-1.0 


9.1 


4.7 


14.7* 


10.1 


83.7 


21.0" 


-4.6 


-0.8 


27.8" 


0.7 


4.5 


0.6 


4.5 


4.9 


14.7* 


14.8** 



Poverty Area 



All Poor 
Poor Urtjan 
Poor Rural 

Non Poor 



-0.1 


4.5 


5.5 


22.8* 


5.2 


10.9* 


-0.6 


3.3 


3.9 


25.1 


3.9 


23.8*' 


53.5 


15.6 


13.7* 


13.3 


6.9 


7.6 


4.6 


0.6 


4.4 


3.8 


15.6* 


14.6* 



Race 



Black 
White 



-0.3 
4.7 



25.5 
0.0 



3.4 
6.1 



6.9 
4.2 



8.7 
14.7 



12.7* 
13.8* 



Medicaid Eligible 



Yes 

No 



4.7 
4.3 



-17.5 
2.7 



5.4 
4.5 



-4.7 
5.6 



19.7* 
15.0* 



13.1 
14.7 



Disabled 



Yes 

No 



0.1 


-10.1 * 


14.3 


9.2 


20.3** 


7.3 


4.9 


2^ 


3.4 


4.3 


14.7 


15.5 



Age 



85+ Years 


-14.6 ** 


-3.5 


1.3 


11.8 


21.2** 


14.0 


Less than 85 


4.9 


0.9 


4.6 


4.7 


15.2* 


14.5 


Residence 














Rural 


46.1 ** 


-2.0 


11.2 


4.3 


6.3 


19.1 


Urtian 


3.6 


1.3 


3.1 


5.0 


25.4** 


4.4 


ALL BENEFICIARIES 


4.4 


0.7 


4.5 


4.8 


15.3** 


14.4 



•Significantly different at the 0.05 level. 
"Significantly different at the 0.01 level. 
Note: AJI statistical tests refer to the 1991-1992 percent change in rates for each group. 



Source: Part A claims and denominator file for a sample of Medicare beneficiaries. 



TABLE IV- 12 

1991 - 1992 PERCENT CHANGES IN ADMISSION RATES FOR PTCA BY MPS PAYMENT CHANGE 
AND VULNERABLE POPULATION GROUPS (age and sex adjusted) 



MFS PAYMENT CHANGE 



Shortage Area 



Poverty Area 



Race 



Medicaid Eligible 



Disabled 



Reduction -^ 



Increase 

6 



Ail Shortage 

Urban 

Rural 
Non-Shortage 



-1.5 % 


12.2 % 


20.6 


43.0 % •* 


17.4 % 


4.4% 


-1.4 


1.9 


24.9 


54.7 • 


21.3 


-8.1 


(a)" 


38.9 - 


2.6 


30.2 * 


15.9 


10.1 


3.6 


21.2 


-0.9 


14.1 


9.6 


5.1 



All Poor 
Poor Urban 
Poor Rural 

Non Poor 



14.4* 


-4.5 


6.2 


42.2- 


38.3- 


12.8 


13.6 


-4.6 


7.0 


31.2 


40.2- 


1.8 


83.6 


-3.7 


1.8 


72.3- 


35.8- 


15.7 


3.1 


21.8* 


-0.7 


14.0 


9.1 


4.6 



Black 
White 



-12.4 
7.2 



0.4 
23.2 



32.1 
-0.5 



16.4 
14.6 



14.4 
8.8 



16.1 
2.7 



Yes 
No 



-2.9 


15.3 


1.9 


40.8 


2.6 


33.1 


4.1 


21.6 


-0.3 


14.0 


10.6 


2.3 



Yes 
No 



2.8 


11.9 


-6.0 


31.3* 


15.8 


20.7 


3.6 


22.3 


0.7 


13.6 


9.1 


2.6 



Age 



85+ Years 


83.0- 


28.4 


133.0 - 


4.2 


54.3* 


-6.5 


Less than 85 


3.2 


21.0* 


-0.5 


15.5 


9.9 


5.1 


Residence 














Rural 


-29.7 - 


18.6* 


27.3- 


30.1 * 


16.2 


7.4 


Urban 


4.4 


21.3 


-4.6 


11.3 


5.4 


-1.2 


ALL BENEFICIARIES 


3.5 


21.0* 


-0.2 


15.4 


10.1 


5.0 



•Significantly different at the 0.05 level. 

**Significantiy different at the 0.01 level. 

(a)Percent change could not be calculated, as the 1991 rate vras 0. 

Note: All statistical tests refer ro the 1991-1992 percent change in rates for each group. 



Source: Part A claims and denominator file for a sample of Medicare beneficiaries. 



TECHNICAL NOTES TO 
APPENDIX IV 



TECHNICAL NOTE A 



TECHNICAL NOTE A 

A stratified random sampling design was developed to ensure large numbers of 
vulnerable beneficiaries living in areas experiencing different levels of MFS payment 
change. The sample was drawn from the 1991 denominator file. All persons eligible 
for both Parts A and B, resident of the 50 States and the District of Columbia, and not 
enrolled in a health maintenance organization constituted the universe, with a total N of 
31,857,201. Our sample design required that every beneficiary on the denominator file 
be categorized into one of 60 strata defined by (1) expected Medicare fee schedule 
(MFS) payment change and (2) vulnerable population subgroup. This technical note 
describes in greater detail just how this categorization was performed. 

MFS Payment Change 

The Health Care Financing Administration calculated expected MFS payment changes 
in 1992 for each reasonable charge locality, taking into account the transition rules in 
effect for the first year of MFS implementation. These changes represented the 
percent change in payments per service, compared with the pre-MFS payment system. 
To the extent that these estimated payment changes were based on 1989 data, they may 
not accurately reflect actual change under the fee schedule. However, there is no 
reason to believe that relative differences in actual payment changes have been any 
different from expected payment changes, i.e., the inter-area MFS impacts should be 
unaffected. 

We cross-walked all reasonable charge localities to MSAs and State rural areas. The 
expected MFS payment change was then merged onto the denominator file, based on 
the MSA-rural area in which the beneficiary resided. Based on a frequency distribution 
of beneficiaries, we then categorized the payment change variable into six groups: 

1. 8 percent or greater reduction. 

2. Between a 5 percent and 8 percent reduction. 

3. Between a 3 percent and 5 percent reduction. 

4. Between a 1 percent and 3 percent reduction. 

5. Between a 1 percent reduction and a 2 percent increase. 

6. 2 percent or greater increase. 

The first two categories represent areas with fairly substantial payment reductions, the 
third and fourth have more modest reductions, and areas in the final two categories 
experienced little change or even increases in payments. 



Vulnerable Population Subgroup 

Nine groups of potentially vulnerable beneficiaries were identified: 

Those residing in a rural health professional shortage area (HPSA); 

Those residing in an urban HPSA; 

Those residing in a rural poverty area; 

Those residing in an urban poverty area; 

Those jointly eligible for Medicaid; 

Black beneficiaries; 

Those originally entitled to Medicare because of disability or end-state renal 
disease; 

The "very" old" (85 years and older); and 

Those residing in any rural area. 

All Medicare beneficiaries not meeting any of these criteria constituted a tenth group. 

All of the variables needed to identify these vTilnerable population subgroups was 
available from the denominator file itself except residence in a HPSA or poverty area. 
Considerable effort was required to construct these measures, as described below. 

HPSAs: A complete hst of HPSAs was published in the September 1991 Federal 
Register. A small number of HPSAs encompass entire counties, but the majority are 
defined as much smaller geographic units: census tracts, census county subdivisions, 
enumeration districts, and the like. The smallest geographic unit available on the 
denominator file is the ZIP code, however. We purchased cross-walks linking census 
tracts (CTs) to ZIP codes and census county subdivisions (CCDs) to ZIP codes from 
two private vendors. These cross-walks included data on the percent of a ZIP code's 
population included in a given CCD or CT. These crosswalks, combined with detailed 
ZIP code maps, enabled us to eventually identify all but a few of the HPSAs in the 
Federal Register . A Medicare beneficiary was defined as living in a shortage area if 50 
percent or more of the ZIP code's population had been identified as residing in an 
HPSA. 

Poverty Areas: A Medicare beneficiary was defined as living in a poverty area, if they 
resided in a ZIP code in which 30 percent or more elderly households were below the 



1991 poverty threshold for a retired couple. Information on the 1991 income 
distribution of elderly households by ZIP code were obtained from a commercial vendor 
of census data. Because the Federal poverty threshold is expressed in nominal dollars 
without any adjustment for geographic cost-of-living differences, we developed and 
applied a methodology for making this adjustment. A paper describing this 
methodology is available from the authors. 

Sample Selection 

Once HPSA and poverty area designation had been determined, all beneficiaries on the 
denominator file were assigned to one of 60 strata (6 payment change categories times 
10 population groups). Sampling algorithms developed by Dr. Martin Frankel (1992) 
were used to select cases within each stratum. Sampling weights were calculated as the 
inverse of the probability of selection. A total of 2,754,770 beneficiaries were selected 
in 1991. 

Individuals who became Medicare-eligible for the first time in 1992 were also assigned 
to one of the 60 strata. These eligibles were then sampled using the same sampling 
probabilities that were applied to individuals in those strata in 1991. A total of 
1,181,577 individuals entered the program for the first time in 1992; of these, a total of 
100,082 were selected into the sample. These beneficiaries were then included in the 

1992 analysis (along with surviving beneficiaries from the 1991 sample). 



TECHNICAL NOTE B 



TABLE IV-B-l 

AMBULATORY CARE SENSITIVE (ACS) ADMISSION RATES IN HEALTH PROFESSIONAL SHORTAGE 
AND NONSHORTAGE AREAS, 1991 (age-sex adjusted admissions per 1,000 beneficiaries) 











NONSHORTAGE 




SHORTAGE AREAS 


AREAS 


ACS Condition 


All 


Urban 


Rural 




Grand Mai Status/Epileptic Convulsions 


0.84 


1.04** 


0.53** 


0.73 


Other Convulsions 


1.32* 


1.60** 


0.87** 


1.11 


Pulmonary Tuberculosis 


0.15** 


0.20** 


0.06 


0.07 


Chronic Obstructive Pulmonary Disease 


7.23 * 


7.43** 


6.89 


6.61 


Bacterial Pneumonia 


11.09* 


10.34 


12.29 ** 


10.39 


Asthma 


3.80** 


4.69** 


2.39 


2.70 


Congestive Heart Failure 


19.12** 


21.53** 


15.28 


15.71 


Hypertension 


1.32** 


1.58** 


0.91 


0.91 


Angina 


7.57** 


7.21 


8.15** 


6.86 


Cellulitis without Skin Grafts 


1.99* 


2.15** 


1.73 


1.74 


Cellulitis with Skin Grafts 


1.15** 


1.47** 


0.63 


0.76 


Diabetes with Ketoacidosis or Coma 


0.51 


0.61 ** 


0.34 


0.41 


Diabetes with Other Complications 


3.53** 


4.10** 


2.62 


2.38 


Hypoglycemia 


0.85** 


1.10** 


0.44 


0.49 


Gastroenteritis 


1.44 


1.24** 


1.76** 


1.50 


Kidney/Urinary Infections 


5.33** 


6.15** 


4.03** 


4.66 


Dehydration 


3.97** 


4.58** 


2.99 


3.28 



TOTAL(a) 



71.83 ** 



77.69 



62.48 



60.77 



•Significantly different from nonshortage areas at the 0.05 level. 
••Significantly different from nonshortage areas at the 0.01 level. 

(a) Includes all ACS admissons, not just those shovm here. 

Source: Part A claims and denominator file for a sample of Medicare beneficiaries, 1991 . 



TABLE IV- B- 2 

AMBULATORY CARE SENSITIVE (ACS) ADMISSION RATES IN POOR AND NONPOOR AREAS, 
1991 (age-sex adjusted admissions per 1,000 beneficiaries) 











NONPOOR 






POOR AREAS 




AREAS 


ACS Condition 


All 


Urban 


Rural 




Grand Mai Status/Epileptic Convulsions 


1.11 ** 


1.20** 


0.77 


0.70 


Other Convulsions 


1.57** 


1.69** 


1.11 


1.09 


Pulmonary Tuberculosis 


0.19** 


0.19** 


0.17** 


0.07 


Chronic Obstructive Pulmonary Disease 


7.62** 


6.86 


10.39 ** 


6.56 


Bacterial Pneumonia 


11.61 ** 


10.53 


15.56 ** 


10.34 


Asthma 


4.10** 


4??** 


3.65** 


2.65 


Congestive Heart Failure 


21.23** 


21.66** 


19.64** 


15.47 


Hypertension 


1.53** 


1.48** 


1.71 ** 


0.89 


Angina 


7.61 ** 


6.96 


10.00 ** 


6.84 


Cellulitis without Skin Grafts 


2.33** 


2.30** 


2.43** 


1.70 


Cellulitis with SIcin Grafts 


1.28** 


1.40** 


0.86 


0.74 


Diabetes with Ketoacidosis or Coma 


0.71 ** 


0.78** 


0.46 


0.39 


Diabetes with Other Complications 


4.11 ** 


4.11 ** 


4.14** 


2.31 


Hypoglycemia 


1.08** 


1.13** 


0.90** 


0.46 


Gastroenteritis 


1.47 


1.23* 


2.37** 


1.50 


Kidney/Urinary Infections 


6.37** 


5.98** 


7.80** 


4.56 


Dehydration 


4.62** 


4.39** 


5.45** 


3.21 



TOTAL(a) 



79.11 



88.24 ** 



76.63 



59.94 



•Significantly different from nonpoor areas at the 0.05 level. 
'•Significantly different from nonpoor areas at the 0.01 level. 

(a) Includes all ACS admissons, not just those shown here. 

Source: Part A claims and denominator file for a sample of Medicare beneficiaries, 1 991 . 



TABLE IV-B-3 

AMBULATORY CARE SENSITIVE (ACS) ADMISSION RATES BY RACE. MEDICAID ELIGIBILITY, 
AND DISABILITY STATUS, 1991 (age-sex adjusted admissions per 1,000 beneficiaries) 





RACE 


MEDICAID EUGIBLE 

Yes No 


DISABLED 


ACS Condition 


Black 


White 


Yes 


No 


Grand Mal Status/Epileptic Convulsions 


1.52" 


0.66 


2.30" 


0.56 


2.00" 


0.59 


Other Convulsions 


227" 


1.03 


2.76 " 


0.94 


2.25 " 


0.99 


Pulmonary Tuberculosis 


0.23 " 


0.06 


0.21 " 


0.06 


0.11 " 


0.07 


Chronic Obstructive Pulmonary Disease 


5.29" 


6.85 


13.99 " 


5.84 


15.92 " 


5.58 


Bacterial Pneumonia 


9.68 " 


10.58 


23.36 " 


9.03 


16.44 " 


9.75 


Asthma 


4.64 " 


2.58 


5.99" 


2.41 


5.88 " 


2.40 


Congestive Heart Failure 


25.25 " 


15.21 


32.56 " 


14.09 


27.15 " 


14.62 


Hypertension 


2.36 " 


0.80 


1.81 " 


0.84 


1.38" 


0.88 


Angina 


6.52 


7.04 


12.38 " 


6.30 


12.64 " 


6.24 


Cellulitis without Skin Grafts 


1.77 


1.76 


3.92 " 


1.51 


3.39 " 


1.56 


Cellulitis with Skin Grafts 


1.73" 


0.69 


2.10 " 


0.63 


1.74" 


0.67 


Diabetes with Ketoacidosis or Coma 


1.33" 


0.33 


1.35" 


0.31 


1.01 " 


0.34 


Diabetes with Other Complications 


5.50" 


2.14 


6.19 " 


2.04 


5.06 " 


2.15 


Hypoglycemia 


1.72" 


0.40 


1.49" 


0.40 


0.96 " 


0.45 


Gastroenteritis 


1.19" 


1.53 


2.75 " 


1.37 


2.26" 


1.41 


Kidney/Urinary Infections 


6.87 " 


4.58 


13.73 " 


3.72 


7.16 " 


4.42 


Dehydration 


5.56 " 


3.11 


8.19 " 


2.79 


4.46" 


3.19 



TOTAL(a) 



84.24 



59.77 



136.09 



53.25 



110.67 



55.75 



'Significantly different from white, non-Medicaid eligible, and nondisabled beneficiaries, respectively, at the 0.05 level. 
"Significantly different from white, non-Medicaid eligible, and nondisabled tjeneficiaries, respectively, at the 0.01 level. 



(a) Includes all ACS admissons, not just those shown here. 

Source: Part A claims and denominator file for a sample of Medicare beneficiaries, 1991 . 



TABLE IV-B-4 



AMBULATORY CARE SENSITIVE (ACS) ADMISSION RATES BY AGE AND AREA OF RESIDENCE, 
1 991 (age-sex adjusted admissions per 1 ,000 beneficiaries) 







AGE 


AREA OF RESIDENCE 


ACS Condition 


85+ Years 


Less than 85 


Rural 


Urban 


Grand Mai Status/Epileptic Convulsions 


0.79 


0.73 


0.65 


0.76 


Other Convulsions 


1.36** 


1.11 


1.02 


1.16 


Pulmonary Tuberculosis 


0.10 


0.07 


0.08 


0.07 


Chronic Obstructive Pulmonary Disease 


4.49** 


6.70 


7.68** 


6.24 


Bacterial Pneumonia 


29.97 ** 


9.89 


12.99 ** 


9.44 


Asthma 


2.35** 


2.77 


2.80 


2.74 


Congestive Heart Failure 


39.18 ** 


15.26 


15.71 


15.97 


Hypertension 


1.02 


0.93 


1.18** 


0.84 


Angina 


10.41 ** 


6.80 


8.69 ** 


6.21 


Cellulitis without Skin Grafts 


4.04** 


1.69 


2.00 * 


1.65 


Cellulitis with Skin Grafts 


2.03** 


0.74 


0.61 * 


0.84 


Diabetes with Ketoacidosis or Coma 


0.57** 


0.41 


0.44* 


0.40 


Diabetes with Other Complications 


1.75** 


2.46 


2.54 


2.41 


Hypoglycemia 


0.80** 


0.50 


0.50 


0.51 


Gastroenteritis 


2.54** 


1.47 


1.94 ** 


1.33 


Kidney/Urinary Infections 


15.92 ** 


4.39 


4.91 


4.61 


Dehydration 


12.24 ** 


3.07 


3.66* 


3.19 


TOTAL(a) 


130.26 ** 


59.46 


67.99 ** 


58.80 



* Significantly different from younger and urtsan beneficiaries, respectively, at the 0.05 level. 
** Significantly different from younger and urtan beneficiaries, respectively, at the 0.01 level. 

(a) Includes all ACS admissons, not just those shown here. 

Source: Part A claims and denominator file for a sample of Medicare beneficiaries, 1991 . 



TABLE IV-B-5 

UTILIZATION OF SELECTED SURGICAL PROCEDURES IN SHORTAGE AND NONSHORTAGE 
AREAS, 1991 (age-sex adjusted procedures per 1,000 beneficiaries) 











NONSHORTAGE 




SHORTAGE AREAS 




AREAS 


Procedure 


M 


Urban 


Rural 




Carotid Endarterectomy 


1.66** 


1.41 ** 


2.07 


2.04 


Colectomy 


3.45** 


3.42** 


3.51 * 


3.89 


Cholecystectomy 


3.36 


3.07 


3.82* 


3.37 


Cholecystectomy, Laparoscopic 


2.30** 


2.06** 


2.68 


2.81 


Hysterectomy (a) 


2.92** 


2.32** 


3.93* 


3.52 


TURP (a) 


17.13 


16.54** 


18.00 


17.68 


Cataract Surgery 


39.44** 


39.82 ** 


38.83 ** 


41.92 



'Significantly different from nonshortage areas at the 0.05 level. 
''Significantly different from nonshortage areas at the 0.01 level. 

(a) Age-adjusted for female and male beneficiaries only, respectively 

Source: Part 6 claims and denominator file for a sample of Medicare beneficiaries, 1 991 . 



TABLE IV- B- 6 

UTILIZATION OF SELECTED SURGICAL PROCEDURES IN POOR AND NONPOOR AREAS, 
1 991 (age-sex adjusted procedures per 1 ,000 beneficiaries) 











NONPOOR 






POOR AREAS 




AREAS 


Procedure 


All 


Urban 


Rural 




Carotid Endarterectomy 


1.17** 


0.92** 


2.08 


2.08 


Colectomy 


3.48 * 


3.65 


2.87** 


3.90 


Cholecystectomy 


3.22 


3.04 


3.87** 


3.38 


Cholecystectomy, Laparoscopic 


2.26** 


1.96** 


3.36 ** 


2.82 


Hysterectomy (a) 


2.47** 


2.33** 


3.02** 


3.57 


TURP (a) 


16.83 * 


16.75 * 


17.10 


17.71 


Cataract Surgery 


39.46 ** 


37.77 ** 


45.70 ** 


41.97 



'Significantly different from nonpoor areas at the 0.05 level. 
**Significantly different from nonpoor areas at the 0.01 level. 

(a) Age-adjusted for female and male beneficiaries only, respectively. 

Source: Part B claims and denominator file for a sample of Medicare beneficiaries, 1991 . 



TABLE IV-B-7 



UTILIZATION OF SELECTED SURGICAL PROCEDURES BY RACE, MEDICAID ELIGIBILITY, AND 
DISABILITY STATUS, 1991 (age and sex-adjusted procedures per 1 ,000 beneficiaries) 





RACE 


MEDICAID ELIGIBLE 

Yes No 


DISABLED 


Procedure 


Black 


White 


Yes 


No 


Carotid Endarterectomy 


0.65** 


2.20 


1.55** 


2.07 


2.40** 


1.97 


Colectomy 


3.34** 


3.99 


3.73 


3.88 


3.50* 


3.91 


Cholecystectomy 


2.56** 


3.49 


4.65** 


3.23 


3.58 


3.34 


Cholecystectomy, Laparoscopic 


1.70** 


2.92 


2.95 


2.76 


2.93 


2.77 


Hysterectomy (a) 


2.40** 


3.61 


2.71 ** 


3.59 


2.85** 


3.53 


TURP (a) 


15.32 ** 


17.89 


15.28 ** 


17.82 


11.24** 


18.90 


Cataract Surgery 


34.25 ** 


43.25 


45.41 ** 


41.39 


31.13** 


42.99 



'Significantly different from white, non-Medicaid eligible, and nondisabled beneficiaries, respectively at the 0.05 level. 
"Significantly different from white, non-Medicaid eligible, and nondisabled beneficiaries, respectively at the 0.01 level. 

(a) Age-adjusted for female and male beneficiaries only, respectively. 

Source: Part B claims and denominator file for a sample of Medicare tseneficiaries, 1991 . 



TABLE IV-B-8 



UTILIZATION OF SELECTED SURGICAL PROCEDURES BY AGE AND AREA OF RESIDENCE, 1991 
(age and sex-adjusted procedures per 1 ,000 beneficiaries) 







AGE 


AREA OF RESIDENCE 


Procedure 


85+ Years 


Less than 85 


Rural 


Urban 


Carotid Endarterectomy 


0.46** 


2.06 


2.10 


1.98 


Colectomy 


4.73** 


3.84 


3.57** 


J^B 


Cholecystectomy 


3.06* 


3.38 


3.62 


J 


Cholecystectomy, Laparoscopic 


1.31 ** 


2.82 


3.21 ** 


^^ 


Hysterectomy (a) 


0.92** 


3.58 


3.54 


IH 


TURP (a) 


26.00 ** 


17.57 


17.97 


17.51 1 


Cataract Surgery 


51.88** 


41.50 


42.39 


41.55 



'Significantly different from younger and urtjan beneficiaries, respectively, at the 0.05 level. 
•"Significantly different from younger and urtian beneficiaries, respectively, at ttie 0.01 level. 

(a) Age-adjusted for female and male beneficiaries only, respectively. 

Source: Part B claims and denominator file for a sample of Medicare beneficiaries, 1991 . 



TABLE IV-B-9 

TOTAL PHYSICIAN SPENDING AND BENEFICIARY LIABILITY FOR VULNERABLE POPULATION 
GROUPS, 1991 (in nominal dollars and age-sex adjusted per beneficiary) 





Total 

PartB 

Physician 

Spending 


Copayments 


Balance 

Billing 

Liability 


Shortaae Areas 








All Shortage Combined 

Urban 

Rural 
Non-Shortage 


$952.22 - 
1,077.63 ** 
752.04 •* 
1,009.16 


$190.44 ** 
215.52 ** 
150.4 •* 
201.83 


$23.06 * 
16.88 * 
32.93 * 
36.08 


Poor Areas 








All Poor Combined 

Urban 

Rural 
Non Poor 


1,079.29 ** 
1,162.69 ** 
772.33 ** 
1,000.21 


215.85 " 
232.53 " 
154.46 ** 
200.04 


17.16 * 
17.31 * 
16.62 " 
36.84 


Race 








Black 
White 


969.87 ** 
1,024.87 


193.97 •* 
204.97 


10.17 * 
38.46 


Medicaid Eliqible 








Yes 
No 


1,282.73 - 
976.04 


256.54 ** 
195.21 


5.65 * 
38.6 


Disabled 








Yes 
No 


1,206.03 ** 
983.32 


241.2 - 
196.66 


26.76 * 
36.35 



Age 



85+ Years 


1,061.93 •* 


212.38 •* 


30.42 


Less than 85 


1,004.55 


200.91 


35.51 


Area of Residence 








Rural 


792.48 " 


158.49 •* 


34.23 


Urban 


1,088.87 


217.77 


35.82 


ALL BENEFICIARIES 


1,005.29 


201.05 


35.37 



'Signtficantly different from comparison group at the 0.05 level. 
"Significantly different from comparison group at the 0.01 level. 



Source: Part B claims and denominator file for a sample of Medicare beneficiaries, 1991 . 



Appendix V 

Changes in Utilization, Access, and Satisfaction With 

Care Among Noninstitutionalized Medicare 

Beneficiaries 



Prepared by: Margo L. Rosenbach, Ph.D. 

and Rezaul Khandker, Ph.D. 

Center for Health Economics Research 

April 1994 

Revised May 31, 1994 



Appendix V 

Changes in Utilization, Access, and Satisfaction With Care 
Among Noninstitutionalized Medicare Beneficiaries 



INTRODUCTION 

This appendix draws on the Medicare Current Beneficiary Survey (MCBS), a survey of 
Medicare beneficiaries sponsored by the Health Care Financing Administration 
(HCFA), that gathers detailed information on utilization, access, and satisfaction within 
the Medicare population. The MCBS is designed as a four-year panel, enabhng 
longitudinal analysis of access impacts. 

This analysis compares utilization, access, and satisfaction among Medicare beneficiaries 
in 1991 and 1992, that is, the year prior to and the year of the introduction of the 
Medicare Fee Schedule (MFS). The analysis focuses on populations that may be 
particularly vulnerable to shifts in the supply of physician services resulting from the 
MFS, defined according to health status, income level, supplemental insurance coverage, 
and expected size of the payment change. 

The MCBS offers a number of advantages over Medicare claims data. First, claims 
data do not contain complete utilization data for enrollees in health maintenance 
organizations (HMOs). The MCBS contains self-reported information on access and 
utilization by all Medicare enrollees. Second, the MCBS gathers information on 
utilization of covered and non-covered services. Claims would reflect covered services 
only. Third, the MCBS gathers detailed information on health status, supplemental 
insurance coverage, income, and other demographic characteristics that may explain 
variations in utilization within the Medicare population. Finally, the MCBS offers a 
variety of access and satisfaction indicators that can be tracked over time. 

The principal disadvantage of the MCBS may be its reliance on self-reported data. To 
the extent that Medicare beneficiaries (or their proxies) have limited recall of health 
care events, data rehability is reduced. To compensate, both self-reported utilization 
data firom the MCBS and matched Medicare claims data for the survey participants are 
included in the analysis. Together, the survey and claims data provide a richer 
understanding of the determinants of access and utilization. 



Appendix V-1 



METHODS 

Sample 

This analysis is based on data from Round 1 and Round 4 of the MCBS. Round 1 was 
conducted between September and December 1991 and Round 4 was fielded one year 
later. The Round 1 sample included 11,735 interviews with individuals residing in the 
community; of these, 10,388 responded to Round 4 of the survey. This analysis includes 
noninstitutionalized Medicare beneficiaries who participated in both rounds of the 
survey. Medicare beneficiaries in Puerto Rico are excluded, as well as those whose 
Medicare coverage dates were unknown (based on HCFA's administrative data). Those 
who died prior to January 1, 1994, were also excluded. Thus, the sample contains a 
panel of continuously enrolled Medicare beneficiaries during 1991 and 1992. We 
exclude those who died in 1993 because they would have been high-volume users in 
1992. In other words, we have omitted a source of bias from the 1992 results which 
would inflate the level of use in 1992, relative to that in 1991 (since 1992 deaths were 
omitted to create the panel). The sample size for this analysis is 8,810. 

Construction of Utilization Measures 

Measures of health care utilization are based on both self-reported survey data and 
administrative claims data. Probability of physician use is based on self reports; 
unfortunately, the data collection procedures differed for the 1991 and 1992 data. In 
Round 1 of the survey, respondents were asked whether they had a visit to an 
emergency room, outpatient department, or physician during the previous year. The 
1992 data reflect the aggregation of responses from Rounds 2, 3, and 4 in which 
respondents were asked whether they had made a visit during the four-month reference 
period for each round. The 1992 data indicate consistently higher rates of utilization 
than the 1991 data. This may be a function of the shorter recall periods for the 1992 
data. 

Barriers to care are measured by whether respondents reported they had a health 
problem in the previous year and did not receive care. The indicator excludes those 
who said they did not receive care because the problem was not serious. Financial 
barriers are identified based on Westat's coding of the open-ended verbatim responses, 
including "cost too much," "didn't have time," "charge more than Medicare will pay," and 
"doctor does not accept Medicare." 

Indicators of the level of outpatient use as well as rates of inpatient use were derived 
from Medicare claims, using 1991 and 1992 National Claims History (NCH) data for 
individuals in the MCBS sample. Individuals who were enrolled in HMOs were . 
excluded from the calculations. In addition, individuals with only Part A Medicare 
coverage were excluded from calculations of office visits and consultations, and 

Appendix V-2 



individuals with only Part B Medicare coverage were excluded from the calculations of 
inpatient admission rates. 

The NCH physician/supplier file was used to count the number of office visits and 
consultations by specialty. The number of services with CPT-4 procedure codes 90000- 
90080 and 90600-90643, and office as the place of service, were aggregated for each 
individual by specialty. Visits to three categories of physician specialty were identified: 
primary care (family practice, general medicine, internal medicine, and osteopathy), 
medical specialties (allergy, cardiology, dermatology, gastroenterology, pulmonary 
disease, geriatric medicine, nephrology, infectious disease, endocrinology, rheumatology, 
hematology/oncology), and other. Office visits/consultations to non-physician specialties 
were counted separately (e.g., psychologists, social workers, podiatrists, optometrists, 
chiropractors). 

Admissions to acute-care hospitals were identified through NCH inpatient hospital and 
skilled nursing facility records for the MCBS population. Special attention is focused 
on ambulatory care sensitive (ACS) admissions, that is, hospitalizations which could 
potentially be avoided if adequately treated on an outpatient basis (Billings et ah, 1992). 
The definition of ACS conditions was adapted to the elderly population for the purpose 
of this analysis'^ An admission was counted as an ACS admission if the primary 
diagnosis on the first claim of a sequence of consecutive inpatient stays has an ACS 
diagnosis. However, transfer cases from nursing homes or other institutions were 
excluded from the count of ACS admissions since these conditions may not reflect lack 
of ambulatory care. 

Statistical Procedures 

Because of the complex sample design (clustering, stratification, and unequal 
probabilities of selection), it is inappropriate to use statistical procedures that assume 
simple random sampling. Weighting and standard error adjustments have been made 
using SUDAAN software, developed by Shah et al. (1992).^ The data have been age- 



'■ The following conditions were included: angina, without surgical procedure; bacterial pneumonia, 
without mention of sickle cell disease; cellulitis (without major surgical procedure); skin graft with 
cellulitis; chronic obstructive pulmonary disease (including chronic, bronchitis, emphysema, asthma, 
bronchiectasis, chronic airway obstruction not classified elsewhere); congestive heart failure; diabetes; 
hypertension; hypoglycemia; kidney/urinary tract infection; tuberculosis, without mention of HIV 
infection. 

^ Weighted means and proportions and their associated standard errors were generated with PROC 
DESCRIPT. All means and proportions are age adjusted using the direct method of standardization. T- 
tests were performed in Excel, using the weighted means and adjusted standard errors. Cross-tabulations 
were performed with PROC CROSSTAB. Chi-square tests are generated by the procedure. Logistic 
regression analysis was performed with PROC LOGISTIC. Beta coefficients, adjusted standard errors, 

Appendix V-3 



adjusted using the direct method of standardization. To control for aging of the 
population, all statistics are standardized according to the baseline (1991) age 
distribution. Tests of statistical significance were conducted both cross-sectionally and 
longitudinally. 

RESULTS 

Characteristics of the Noninstitutionalized Medicare Population 

The noninstitutionalized Medicare population was comprised primarily of elderly 
individuals (age 65 and over), who accounted for 91 percent of the enroUees in 1992 
(Table 1). Women represented over one-half (57.5 percent) of all noninstitutionalized 
enroUees; men, however, represented a disproportionate share of the disabled. About 
85 percent of the population was non-Hispanic white and the remaining 15 percent 
included individuals of other races/ethnicities. Minorities were disproportionately 
represented among the disabled (under age 65). The disabled have lower educational 
attainment, perhaps reflecting the inclusion of dependent adults who were disabled in 
childhood (Lubitz and Pine, 1986). The elderly were more likely than the disabled to 
have close social supports, such as a spouse or child. 

As might be expected, the disabled had a lower-income distribution, with 86 percent 
having incomes of $20,000 or less per year (compared with 76 percent of the elderly). 
Similarly, the availability of supplemental insurance coverage varied, with 26 percent of 
the disabled but only 8 percent of the elderly having no supplemental coverage. In 
addition, the disabled were about four times more likely than the elderly to have joint 
Medicaid eligibility. Three-fourths of the elderly, but only one-third of the disabled, 
had private Medigap coverage. 

Three-fourths of the noninstitutionalized Medicare population resided in areas that are 
expected to experience more than a 1-percent reduction in fees.^ One-third (35 
percent) were in areas expecting a small fee reduction; one-fourth (26 percent) were in 
medium fee reduction areas; and 13 percent were in high fee reduction areas. Of the 
remainder, 16 percent were in areas that were expected to have increases of 



and adjusted p-values are produced. Weighted least squares was performed on visit counts using PROC 
REGRESS. 



^ HCFA calculated expected MPS payment changes in 1992 for each reasonable charge locality, 
taking into account the transition rules in effect for the first year of MPS implementation. These 
changes represented the percent change in payments per service, compared with the pre-MFS payment 
system. They may not accurately reflect actual change under the fee schedule because these estimated 
payment changes were based on 1989 data, and they do not incorporate the 1992 update. 



Appendix V-4 



1-10 percent, while 10 percent resided in areas expecting no more than a 1 percent 
change in either direction. 

The disabled were in poorer health than the elderly, as measured by both perceived 
health status and limitation of activity. Finally, the geographic distribution was fairly 
similar between the two groups, although the disabled were slightly more likely to reside 
in rural areas. 

Descriptive Analysis of Changes in Utilization, Access, and Satisfaction 

Variations among the disabled and elderly populations 

Table 2 presents utilization, access, and satisfaction indicators for 1991 and 1992. 
Multiple indicators are being tracked to develop a comprehensive picture of the impact 
of the Medicare Fee Schedule on beneficiary access to care. Both cross-sectional and 
longitudinal differences are tested for statistical significance. Significant time-series 
differences are denoted by the symbol (a) on the table, while cross-sectional differences 
are indicated by an asterisk. Our focus is on the time trends. 

The likelihood of physician use increased significantly between 1991 and 1992, for both 
the disabled and the elderly. For example, 86.5 percent of Medicare beneficiaries had 
a physician visit in 1991 versus 90.4 percent in 1992. 

The likelihood of ambulatory visits to hospital-based settings has also increased 
significantly over the two-year time period." In 1991, 27 percent of Medicare 
beneficiaries had a visit to an outpatient department, compared with 36 percent in 
1992. Similarly, the percent with an emergency room visit increased from 18 percent to 
22 percent. ER and OPD use was consistently higher among the disabled population 
than the elderly, perhaps because of their complex medical needs or because of other 
barriers to office-based care. An important question to be addressed in the 
multivariate analysis is whether the increased use of hospital-based providers is 
associated with the implementation of the Medicare Fee Schedule. 

According to Medicare claims data for the survey sample, the average number of office 
visits per user increased significantly among the elderly, from 6.2 to 6.5 visits. Thus, 
both utilization rates and levels have increased significantly between 1991 and 1992 for 
the elderly. 

There were no significant trends in the rate of hospitalization or the percent of 
admissions with an ambulatory care sensitive condition. 



Significant increases in ER and OPD use were also exhibited in the claims data. 

Appendix V-5 



The likelihood of a flu shot among the elderly increased between 1991 and 1992 from 
42.7 percent to 49.1 percent. Effective May 1, 1993, flu injections were reimbursed 
under Medicare, suggesting that the rate may increase even higher in the future. 

Breast cancer screening among women decreased between 1991 and 1992 (39 percent 
versus 34 percent). However, this is likely a function of the reimbursement regulations 
and not an indicator of declining access. Effective January 1, 1991, screening 
mammography was added as a new Medicare Part B benefit. The frequency of 
screening is based on a woman's risk of developing breast cancer, as well as her age. 
For women age 65 and older, the procedure is limited to one per 23-month period. 
Thus, women who were screened in 1991 would not be rescreened in 1992, unless they 
were at high risk. 

Pap smears were reimbursed under Medicare as of July 1, 1990, and are covered at 
three-year intervals, except for women at high risk of developing cervical cancer. This 
would explain in part the decrease in the percent of women receiving a Pap smear in 
1991 (49 percent) versus 1992 (33 percent). 

Perceptions of barriers to care have decreased within the Medicare population, 
suggesting that overall concerns about access following the implementation of the 
Medicare Fee Schedule are unfounded. Finally, satisfaction with care seems to have 
improved significantly along three of the four dimensions measured (quality, availability, 
and costs).^ The disabled, however, continue to be less satisfied with their medical care 
than the elderly. For example, 69 percent of the disabled but 80 percent of the elderly 
were satisfied with the costs of medical care in 1992. Nevertheless, both groups were 
more satisfied in 1992 than in 1991. Additionally, reductions in extra billing and 
increases in physician participation rates may account for increased satisfaction with 
costs.* 

Variations by Level of 1992 Medicare Fee Reductions 

The key pohcy interest is whether patterns of utilization, access, and satisfaction 
changed significantly in areas that had the highest Medicare payment reductions or 
payment increases (Table 3). The likelihood of any visit as well as a non-hospital visit 



■^ Observed increases in satisfaction may be an artifact of the survey itself, whereby respondents' 
perceptions of the program are affected by the survey intervention, rather than due to actual changes in 
the program. This is known as the Havvthorne effect. 

* The maximum extra billing was reduced from 125 percent of the allowed charge in 1991 to 120 
percent in 1992. In addition, the physician participation rate rose from 44.0 percent in 1991 to 48.3 
percent in 1992, 

Appendix V-6 



was highest at basehne (1991) in areas expecting the largest decreases. The areas 
expecting the greatest fee reductions tend to be the large MSAs in California, Arizona, 
and Florida, areas with large numbers of retirees, and with relatively high proportions 
of beneficiaries who are well off financially. 

All areas experienced significant increases in the likelihood of a visit between 1991 and 
1992, but relatively smaller increases were experienced in the high fee reduction areas. 
As a result, there were no longer significant differences in the probability of use 
between beneficiaries in the high fee reduction and no change areas. The likelihood of 
an OPD visit and an ER visit also increased significantly in all but the high fee 
reduction areas. In general, gaps in the number of visits per user also narrowed across 
areas following the introduction of the Medicare Fee Schedule. 

Satisfaction with the quality, availability, and convenience of medical care remains high 
in all areas. Interestingly, Medicare beneficiaries reported greater satisfaction in 1992 
with the availability of care. Satisfaction with the costs of care also increased 
significantly in all aeas, and as would be expected, the rate of change was highest in the 
areas expecting a reduction in fees. 

Table 4 shows attitudes toward the usual source of care according to the level of fee 
schedule changes expected in 1992. In general, attitudes are extremely positive, with 
the most agreement concerning physician competency and training. Between 1991 and 
1992, Medicare beneficiaries noted less often that their usual doctor seemed to be in a 
hurry, that their doctor does not discuss health problems, or that their doctor acts as if 
he/she is doing a favor. Improved attitudes may be a function of higher compensation 
for primary care services and/or the restructuring of reimbursement for evaluation and 
management services. 

Variations by Health Status 

Health status is generally the strongest predictor of health care utilization. As shown in 
Table 5, the probability and volume of physician use increases as health status declines. 
For example, 82 percent of those in excellent health made a visit in 1992, compared 
with 94 percent of those in poor health. In addition, the average number of visits per 
user differed by nearly two-fold (4.7 versus 9.2). Eleven percent of those in excellent 
health but 45 percent of those in poor health made an emergency room visit. Similarly, 
8 percent of those in excellent health versus 33 percent of those in poor health had a 
hospitalization in 1992. The rate of ambulatory care sensitive admissions ranged from 
1.4 percent for those in excellent health to 9 percent for those in poor health. 

Between 1991 and 1992, the likelihood of a non-hospital visit increased for all Medicare 
beneficiaries except for those in poor health. ER and OPD use increased significantly 
as well. 

Appendix V-7 



Influenza immunization rates increase as health status decreases, consistent with the 
guidehnes (U.S. Preventive Services Task Force, 1989). All groups had significantly 
higher rates of immunization in 1992 than 1991. 

Barriers to care and satisfaction with care also vary by health status. About l-in-34 
enroUees in excellent health reported a barrier in 1992, compared with about l-in-5 of 
those in poor health. Only those in very good and good health reported a decrease in 
the extent of barriers to care between 1991 and 1992. 

Satisfaction with quality, availability, convenience, and costs also declines with health 
status. In 1991, 81 percent of those in excellent health, but only 54 percent of those in 
poor health were satisfied with the costs of medical care. However, this gap narrowed 
over the two-year time period. Those in poor health ~ high users of medical care ~ 
had an 11 percentage point increase in satisfaction between 1991 and 1992. 

Variations by Income and Supplemental Insurance Coverage 

Finally, we examine changes in utilization according to income level and type of 
supplemental insurance coverage. The probability of having any physician visit rises 
with income (Table 6). Among users, however, the average number of visits decreases 
with income. This suggests that low income serves as a barrier to entering the health 
care system, although those who enter are higher users, undoubtedly due to poorer 
health status. Low-income beneficiaries used the emergency room more than those 
with higher incomes, and were less likely to receive preventive care. Low-income 
beneficiaries continued to report a higher incidence of barriers (despite significant 
improvements in this indicator) and the majority of unmet need was due to financial 
factors. Consistent with these results is a higher likelihood of hospitalization with an 
ambulatory care sensitive condition. Finally, although satisfaction levels increased within 
the Medicare population, lower-income enroUees remained less satisfied with the 
quality, costs, and convenience of medical care. 

Medicare beneficiaries with public or private supplemental insurance coverage were far 
more likely to see a physician than those with no supplemental coverage (Table 7). In 
1992, 76 percent of those with Medicare only made at least one physician visit to any 
setting, compared with 92-93 percent of those with supplemental coverage. It is not 
clear whether this is a function of less "need" for care or less financial access to care. 
However, other indicators show that the Medicare-only group was least likely to have a 
regular source of care and also most likely to experience a financial barrier. They also 
have the lowest rating of satisfaction with the costs of care. 

Those with dual Medicare and Medicaid coverage had much higher emergency room 
use than those with Medicare coverage only. In 1992, one of every three dual enrollees 

Appendix V-8 



made an ER visit, compared with one-in-five enrollees with no supplemental coverage. 
Again, this could be attributable to poorer health status; nevertheless, dual enrollees 
had a high rate of access barriers (10.4 percent) and were least satisfied with the ease 
of getting to the doctor. This group also had the highest rate of admissions for 
ambulatory care sensitive conditions. 

Multivariate Analysis of Determinants of Utilization and Satisfaction 

Overview of the model 

While descriptive analysis examines one variable at a time to determine its impact on 
utilization and access, multivariate analysis simultaneously controls for multiple factors 
affecting utilization. Thus, the effect of an individual factor (such as the effect of 
income or insurance status) on utilization is determined independent of other factors, 
that is, holding other factors constant. An important focus of the multivariate analysis 
is to determine patterns of utilization in areas with different degrees of payment change 
following implementation of the Medicare Fee Schedule in 1992, isolating the effect of 
such factors as demographic, economic, and health status characteristics. 

Logistic regressions were performed on the probability of a physician visit in any setting 
(any visit), emergency room visit (ER visit), outpatient department visit (OPD visit), 
inpatient admission, satisfaction with cost, and satisfaction with availability of care. In 
addition, weighted least squares regression was performed to determine if the number 
of visits per user had changed from 1991 to 1992, after controlling for various factors. 

The unit of analysis is a person-year. Thus, data for each beneficiary were pooled for 
1991 and 1992. The effect of the Medicare Fee Schedule is modeled using three sets 
of dummy variables: 

The first, a year dummy, captures the secular trend between 1991 and 1992; 

The second, a series of payment change dummy variables, captures the cross- 
sectional differences across geographic areas according to the expected level of 
the payment change; and 

The third, an interaction term between the yearly trend and level of payment 
change, indicates whether the Medicare Fee Schedule has had a significant 
impact on utilization and satisfaction, above and beyond the secular trend, and 
independent of the pre-existing differences across areas receiving differential 
payment changes. 

In addition to the fee schedule indicators, the multivariate model includes predisposing, 
enabling, and need characteristics that are hypothesized to affect the probability or 

Appendix V-9 



volume of use. Predisposing characteristics include age, sex, race/ethnicity, educational 
status, living arrangement, and whether there are living children. Enabling 
characteristics include financial variables (income status, supplemental coverage), regular 
source of care, and physician availability (physicians per capita in the county of 
residence). Need characteristics include both perceived health status, and the level of 
dependency. We also control for geographic location (Census division and urban/rural 
location).^ 

Logistic regression estimates the logarithm of relative odds. These were translated into 
probabilities of use and satisfaction by using the logistic transformation and evaluating 
the predicted equation at average values of the regressors. For the time-trend and 
payment-change area variables, we turned on and off particular cells. For example, to 
calculate the predicted probability in 1992 of any physician visit for the "high reduction 
area" (5 to 11 percent decrease), we turned on the year 1992 indicator and the area- 
specific indicator, and the interaction term (since both terms in the interaction were 
equal to 1). 

Effect of Medicare payment changes on utilization 

The primary variable of interest is the effect of the level of Medicare payment changes 
on utilization following the introduction of the Medicare Fee Schedule. The variable 
represents, on a continuous scale, the percentage change in physician payment from 
1991 ("pre" fee schedule change) to 1992 ("post" fee schedule change). Since some 
areas have experienced a reduction in payment while other areas experienced an 
increase, higher values for this variable either imply lower levels of payment reduction 
or an increase in payment depending on the specific area. 

Table 8 reports logistic regression estimates for the equations on physician visit in any 
setting, emergency room and outpatient department visits, inpatient admission, and 
satisfaction with cost and availability of medical care. All of the equations were found 
to be statistically significant (as evidenced by the overall F test). The R-squares ranged 
from 0.03 (satisfaction with availability of care) to 0.19 (probability of any visit). 

The "YEAR 1992" variable represents the yearly time trend (equals 1 if year = 1992, 
equals if year = 1991). The yearly trend coefficients are positive and significant for 
any physician visit, outpatient department and emergency room visits, as well as 
satisfaction with cost. The significant trends indicate that there was an overall (secular) 
increase in the likelihood of visits across all payment-change areas. It is interesting to 



7 As might be expected, the geographic variables were correlated with the Medicare payment change 
dummy variables. However, the results on the fee schedule variables are not altered with the inclusion of 
the geographic variables. 

Appendix V-10 



note that beneficiaries reported an increase in satisfaction with the cost, but not 
availability, between 1991 and 1992. 

The variable, "Medicare Payment Change" shows if there is any cross-sectional variation 
in utilization and satisfaction across payment-change areas. This variable is rarely 
significant. Only areas with the highest payment reduction had a significantly lower 
likelihood of inpatient stay and a higher likelihood of physician visits. These estimates 
are relative to areas with no payment change. 

The interaction of payment-change area and time trend (Year 1992 X Medicare 
Payment Change) estimates if there is a differential trend for a particular payment 
change area over and above the secular change. These estimates are insignificant 
except in a few instances. The probability of an outpatient department visit showed a 
significantly lower rate of increase between 1991 and 1992 in the areas with a 1 to 3 
percent or 5 to 11 percent payment reduction as well as in the payment increase areas 
(relative to "no change" areas). Thus, most payment change areas experienced a 
smaller rate of increase in outpatient department visits. 

Another variable which showed significant trends across the high reduction areas (3 to 
11 percent reduction) is satisfaction with the cost of care. The increase in satisfaction 
with the cost of medical care is perhaps in part related to the reduced extra billing 
limits. The base for allowed extra bilHng would also decline most in these areas. 

Table 8 also reports weighted least squares estimates for the number of visits per user. 
We did not observe any significant secular trend, cross-payment area variation, or trend 
differential across areas for the number of visits. 

Table 9 reports predicted probabilities of outpatient department visits and satisfaction 
with the cost of care.* These two measures exhibited significant time trends across 
payment areas. The results reported in Table 9 can be summarized as follows: 

Most fee reduction areas had a slower rate of growth in the use of 
outpatient department visits relative to areas expecting no fee change. 
While the "no change" areas had a 64 percent increase in the likelihood of 
an outpatient visit, highest payment reduction areas showed an increase of 
only 17 percent. We do not find any evidence of substitution of other 
services to offset this decline in OPD use. 



* The probabilities are based on the logistic regression coefficients, and are evaluated for an average 
person in the sample (that is, controlling for variation in the population in terms of demographic, financial, 
health status, and other characteristics). 

Appendix V-11 



High fee reduction areas had a greater improvement in satisfaction with 
the cost of care relative to the "no change" areas. Highest payment 
reduction areas experienced a 15 percent increase in satisfaction rates 
while "no change" areas experienced only a 7 percent increase. 

Effects of other variables 

The effect of age varies depending on the type of utilization (Table 8). As age 
increases, the likelihood of any physician visit, emergency room visit, and 
inpatient admission decreases, but the rate of decline slows with age (u-shaped 
relationship). For OPD visits, number of visits, and satisfaction with availability, 
the relationship is of the opposite nature (inverted u-shaped). 

Males have a lower likehhood of any physician visit, but a higher likelihood of 
emergency room visits and inpatient admissions. Males are also more likely to 
be satisfied with the cost of care. 

Relative to whites, blacks are more likely to have an emergency room visit, and 
less likely to be admitted to hospitals. Other Medicare beneficiaries (non-white, 
non-Hispanic, rion-black) also had a significantly lower rate of admission. 

Education has a positive and significant relationship with the probability of any 
visit, an OPD visit, and inpatient use. Perhaps surprisingly, those with lower 
levels of education were more satisfied with the availabihty of care than those 
with higher levels of education (over 12 years). ER and inpatient use was higher 
among those living alone or with nonrelatives compared to those living with a 
spouse. Higher hospital use (both inpatient and ER) may result because fewer 
social supports are available. However, those with living children had a higher 
likelihood of an emergency visit and an inpatient admission, and were less likely 
to be satisfied with cost. 

Low-income Medicare beneficiaries were less likely to see a physician and less 
likely to be satisfied with the cost of care. Those with incomes below $10,000 
also had a lower rate of OPD visits. Low income beneficiaries may experience 
financial barriers to care. However, there was no significant difference between 
high income ($35,000 or more) and low income ($20,000 or less) groups in the 
number of visits per user. 

Insurance status, a proxy for the out-of-pocket price of care, also appears to be 
a significant determinant of use. Having any type of supplemental coverage 
raises the probability of a physician visit as well as the number of visits among 
users. Inpatient admissions are also higher for these individuals. Not 
surprisingly, individuals with any type of supplemental coverage are more likely 

Appendix V-12 



to be satisfied with the cost of care. Relative to the Medicare-only group (no 
supplemental coverage), individuals with Medicaid and other supplemental 
coverage have a significantly higher likelihood of an ER visit. Those with other 
supplemental coverage have a higher likelihood of an OPD visit. 

As might be expected, individuals with a regular source of care have a higher 
likelihood of seeing a physician. Moreover, individuals with a regular physician 
(either in an office-based setting or other place) have more visits and are also 
more likely to have an inpatient admission. Interestingly, individuals with a 
physician's office as the regular source are less likely (relative to those with no 
regular source) to be satisfied with cost. 

Area-specific availability of physicians per capita is negatively associated with the 
likelihood of ER visits and positively associated with the likelihood of OPD 
visits and the number of office visits. In areas with a greater supply of 
physicians, availability of non-hospital ambulatory care may lower the need for 
ER visits. More physicians may mean more visits to physicians' offices and 
outpatient departments, either as a result of supply induced demand, or due to 
increased knowledge and awareness about health care needs from prior physician 
contacts. Interestingly, individuals in areas with a higher concentration of 
physicians are less likely to be satisfied with the cost of care. 

Health status measures are also consistent predictors of the probabihty and 
volume of health service use. As the level of health status deteriorates, there is 
an increased likelihood of ambulatory visits and inpatient admissions and an 
increase in the number of visits. In addition, as the level of dependency 
increases, the likelihood of physician and ER use as well as inpatient use 
increases, relative to those without an activity limitation. The number of visits 
also increases for those with limitations in activity (up to 4 ADLs), but not 
beyond (5-6 ADLs) because visits are limited at very high levels of inactivity. In 
general, more hmitation in activity is associated with a lower satisfaction with 
care. 

Geographic location is not a strong predictor of the probability of use, but 
appears to be significantly related to the volume of visits. All areas have fewer 
visits per user than the Pacific states. These states tend to have high outpatient 
use and low inpatient use. Not surprisingly, individuals living in urban areas are 
more likely to report satisfaction with the availabihty of care. 



Appendix V-13 



DISCUSSION 

This appendix has analyzed utilization, access, and satisfaction within the 
Medicare population, before and after the implementation of the Medicare Fee 
Schedule. Several encouraging trends were found. First , perceptions of barriers 
to care have decreased within the Medicare population, suggesting that overall 
concerns about access are unfounded. Second , satisfaction with care seems to 
have improved along three of the four dimensions measured (quality, availability, 
and costs). Interestingly, satisfaction with the costs of care increased most in the 
areas experiencing a reduction in fees. In addition to the Medicare Fee 
Schedule, other factors may account for greater satisfaction with costs, including 
higher physician participation rates and further limitations on balance billing. 
Third , altitudes towards the usual source of care have improved. Fewer 
Medicare beneficiaries are reporting that their doctor seemed to be in a hurry, 
that their doctor does not discuss health problems, or that their doctor acts as if 
he/she is doing a favor. Improved attitudes may be a function of higher 
compensation for primary care services and/or the restructuring of 
reimbursement for evaluation and management services. Future analyses should 
assess the impact of the Medicare Fee Schedule on vulnerable populations, 
including the disabled, oldest-old, minorities, low income, those with no 
supplemental coverage and those in poor health. 

Several caveats should be noted. First, this analysis is based on data for two 
years - the year before and the first year of the Medicare Fee Schedule. 
Physician payment changes may impact utilization differently over time, and the 
long run impacts are unknown at this point. There may be other confounding 
factors in the short run which we could not fully capture. Second, the measure 
of expected Medicare payment change is exactly that ~ expected ~ and not 
actual. Moreover, the payment change areas are matched according to where 
Medicare beneficiaries live and do not necessarily coincide with where their 
providers practice. Measurement error on this key variable may result in 
measurement error in the regression analysis. Third, the model uses the 
beneficiary as the unit of analysis, while areas are used to measure payment 
changes. As such, area-specific factors which account for utilization differences 
may confound the results. At the same time, individual-specific factors may 
dilute the effect of payment changes. Future modeling could adjust for this 
feature using a quasi-fixed effects model with area-specific dummy variables to 
control for area factors. Alternatively, payment change effects could be 
measured at the individual, rather than area, level. 



Appendix V-14 



REFERENCES 

Billings, J., Zeitel, L., Lukomnik, J., Carey, L., Blank, A., Newman, L. "Analysis 
of Variation in Hospital Admission Rate Associated with Area Income in New 
York City," unpublished manuscript, March 1992. 

Lubitz, J., and Pine, P. "Health care use by Medicare's disabled enrollees," 
Health Care Financing Review, Summer 1986, Vol. 7, No. 4. 

Shah, B.V., Barnwell, B.G., Hunt, P.N., LaVange, L.M. SUDAAN User's 
Manual. Release 5.0 . Research Triangle Park, N.C.: Research Triangle 
Institute, 1991. 

U.S. Preventive Services Task Force: Guide to Clinical Preventive Services . 
Baltimore, MD. William and Wilkins, 1989. 



Appendix V-15 



TABLE V- 1 

CHARACTERISTICS OF THE NONINSTITUTIONALIZED MEDICARE POPULATION: 1992(a) 



Age 

Under age 45 
Ages 46-64 
Ages 65-69 
Ages 70-74 
Ages 75-79 
Ages 80-84 
Age 85 and over 

Sex 

Male 
Female 

Race/Ethnicity 

White 
Black 
Hispanic 
Other 



All Medicare 


Disabled 


Elderly 


Beneficiaries 


(Under Age 65} 


(Age 65 and Over) 


fn=8.810) 


(n=1,530) 


fn=7.280) 


2.9% 


33.3 % 




5.8 


66.7 


— 


21.1 


- 


23.1 % 


28.0 


- 


30.7 


20.9 


- 


22.9 


13.0 


— 


14.3 


8.3 


— 


9.0 



42.5 
57.5 



85.2 
9.0 
4.1 
1.7 



61.9 
38.1 



73.5 

17.9 

6.6 

2.0 



40.7 
59.3 



86.3 
8.1 
3.8 
1.7 



Educational Attainment 

Less than 6 years 

6-1 1 years 

12 years 

More than 12 years 

Living Arrangement 

Living with spouse 
Living with others 
Living alone 

Living Children 

One or more 
None 



11.6 
31.1 
31.7 
25.6 



53.5 
17.1 
29.4 



85.8 
14.3 



16.4 
33.1 
34.3 
16.3 



40.5 
38.4 
21.1 



65.7 
34.3 



11.1 
31.0 
31.4 
26.5 



54.7 
15.1 
30.2 



87.6 
12.4 



Income Status 

$10,0CX}orless 
$10,001 to $20,000 
$20,001 to $35,000 
$35,000 or more 

Insurance Coverage 

Medicare only 
Medicare and Medicaid 
Medicare and Private Coverage 
Medicare and Other Coverage 



46.5 

30.4 

15.0 

8.2 



9.8 

8.4 

73.3 

8.5 



64.0 

22.0 

10.5 

3.5 



26.0 
28.6 
33.7 
11.8 



44.9 

31.2 

15.4 

8.6 



8.3 

6.5 

77.1 

8.2 



TABLE V-1 (Continued) 

CHARACTERISTICS OF THE NONINSTITUTIONALIZED MEDICARE POPULATION: 19S2(3) 



All Medicare Disabled Elderly 

Beneficiaries (Under Age 65) (Age 65 and Over) 

(n=8.810) (n=1.S30) (n=7.280) 

Medicare Fee Schedule 
Payment Change. 1992 

-11 to -5 percent 13.1% 10.0% 13.4% 

-5 to -3 percent 25.9 27.2 25.8 

-3 to -1 percent 35.0 31.9 35.3 

-1 to +1 percent 10.4 10.7 10.4 

1 to 10 percent 15.6 20.2 15.1 

Perceived Health Status 

Excellent 17.0 6.4 18.0 

Very Good 27.1 12.1 28.5 

Good 30.0 24.7 30.5 

Fair 17.9 29.2 16.9 

Poor 7.9 27.7 6.0 

Level of Dependency 

None 62.0 33.4 64.7 

lADLSonly 7.1 19.7 5.9 

1-2ADLS 21.1 27.9 20.5 

3-4ADLS 6.8 12.8 6.2 

5-6ADLS 3.1 6.3 2.8 

Census Division 

New England 3.7 3.0 3.8 

Middle Atlantic 18.4 16.4 18.6 

East North Central 17.8 17.1 17.9 
West North Central 6.5 6.0 6.5 

South Atlantic 19.5 23.1 19.2 
East South Centra! 5.6 9.1 5.3 

West South Central 9.9 8.9 9.9 

Mountain 5.6 5.4 5.7 

Pacific 13.0 11.2 13.2 

Urbanicity 

Urban 72.4 67.4 72.8 

Rural 27.6 32.6 27.2 



(a) Includes noninstitutionalized Medicare beneficiaries who participated in Round 1 and Round 4 of the Medicare Current 
Beneficiary Survey and were alive as of January 1, 1994. The weighted population projection is 26.83 million Medicare 
beneficiaries, of which 2.32 million enrollees are under age 65 and 24.51 million enrollees are age 65 and over. 

Source: Medicare Current Beneficiary Survey, Round 4 Data, Primary analysis by the Center for Health Economics 
Research. 



TABLE V-2 

UTILIZATION, ACCESS, AND SATISFACTION INDICATORS, BY AGE: 1991 - 1992 



1991 



1992 



All Elderly All Elderly 

Medicare Disabled (Age 65 Medicare Disabled (Age 65 

Beneficiaries (Under Age 65) (and Over) Beneficiaries (Under Age 65) (and Over) 



Type of Regular Source 

Physician's office 

Other place with regular physician 

Other place with no regular physician 

None 

Physician Use 

Percent with: 

Physician visit (any setting) 
Physician visit in non-hospital setting 
Outpatient department visit 
Emergency room visit 

Average number of office visits per user. 
Total 

To primary care physician 
To medical specialist 
To other specialist 
To non-physician 

Hospital Use 

Percent with hospitalization 
Percent with ACS condition 

Preventive Use 

Percent with flu shot in previous winter 
Percent of women with mammogram 

in previous year 
Percent of women with Pap smear 

in previous year 

Barriers to Care 

Percent reporting a health problem and 
not receiving care in previous year 
Of those, percent reporting a 
financial barrier 

Satisfaction with Care 

Percent satisfied with: 
Quality of medical care 
Availability of medical care 
Ease of getting to doctor 
Costs of medical care 



67.0% 


57.3% • 


68.0% 


69.4% 


58.4% * 


70.4% 


19.7% 


24.6% * 


19.2% 


16.9% 


20.0% 


16.6% 


4.5% 


9.1% 


4.0% 


4.1% 


9.2% * 


3.6% 


8.8% 


9.0% 


8.8% 


9.7% 


12.4% 


9.4% 



86.5% 


86.1% 


86.5% 


90.4% 


(a) 


89.3% 


(a) 


90.5% 


(a) 


83.6% 


81.4% 


83.9% 


87.2% 


(a) 


82.5% 


* 


87.7% 


(a) 


26.7% 


33.5% * 


26.0% 


36.3% 


(a) 


41.6% 


*(a) 


36.9% 


(a) 


17.8% 


28.5% * 


16.6% 


21.8% 


(a) 


34.1% 


-(a) 


21.3% 


(a) 


6.2 


6.3 


6.2 


6.5 


(a) 


6.4 




6.5 


(a) 


4.6 


4.6 


4.6 


4.6 




4.4 




4.6 




3.0 


3.5 * 


3.0 


3.2 




4.0 


* 


3.2 




3.2 


3.7 * 


3.2 


3.2 




3.6 


* 


3.2 




2.1 


2.1 


2.1 


2.1 




2.1 




2.1 




15.2% 


18.4% * 


14.8% 


15.1% 




17.4% 


. 


15.1% 




3.5% 


4.4% 


3.4% 


3.6% 




4.4% 




3.6% 




41.0% 


24.5% * 


42.7% 


47.6% 


(a) 


26.6% 


• 


49.1% 


(a) 


39.1% 


30.8% * 


40.0% 


33.6% 


(a) 


30.1% 




34.2% 


(a) 


49.1% 


55.3% * 


48.5% 


33.4% 


(a) 


41.8% 


*(a) 


33.6% 


(a) 



9.5% 


22.8% * 


8.1% 


7.4% (a) 


19.3% *(a) 


6.8% (a) 


53.8% 


69.8% * 


52.2% 


56.7% 


71.2% • 


55.8% 



94.5% 


88.9% * 


95.1% 


96.1% 


(a) 


92.0% 


*(a) 


96.4% 


(a) 


94.2% 


88.7% * 


94.8% 


96.4% 


(a) 


92.8% 


*(a) 


96.4% 


(a) 


92.6% 


83.5% * 


93.6% 


93.6% 




88.0% 


*(a) 


93.9% 




71.0% 


61.1% * 


72.0% 


79.7% 


(a) 


69.4% 


*(a) 


80.2% 


(a) 



* Significantly different from those age 65 and over (p<0.05). 

(a) Significantly different over time (1991 - 1992). 

Note: Age-adjusted using the direct method of standardization. 

Sources: Medicare Cun-ent Beneficiary Sun/ey. Round 1 and Round 4 Data; Medicare NCH Claims for MCBS Population. 
Primary analysis by the Center for Health Economics Research. 



TABLE V-3 

UTILIZATION, ACCESS, AND SATISFACTION INDICATORS. BY LEVEL OF 1992 MEDICARE FEE SCHEDULE CHANGE: 1991 - 1992 



1991 



1992 



Type of Regular Source 

Physician's office 

Other place with regular physician 

Other place with no regular physician 

None 

Physician Use 

Percent with: 

Physician visit (any setting) 
Physician visit in non-hospital setting 
Outpatient department visit 
Emergency room visit 

Average number of office visits per user 
Total 

To primary care physician 
To medical specialist 
To other specialist 
To non-physician 

Hospital Use 

Percent vi/ith hospitalization 
Percent with ACS condition 

Preventive Use 

Percent writh flu shot in previous winter 
Percent of women with mammogram 

in previous year 
Percent of women with Pap smear 

in previous year 

Barriers to Care 

Percent reporting a health problem and 

not receiving care in previous year 
Of those, percent reporting a 
financial barrier 

Satisfaction with Care 

Percent satisfied with: 
Quality of medical care 
Availability of medical care 
Ease of getting to doctor 
Costs of medical care 







Plus or 










Plus or 




5 to 11% 


3 to 5% 


1to3% Minus 1% 


1 to 10% 


5 to 11% 


3 to 5% 


1 to 3% 


Minus 1% 


1 to 10% 


Reduction 


Reduction Reduction Chanoe 


Increase 


Reduction 


Reduction 


Reduction 


Change 


Increase 


66.3% 


64.3% 


67.4% * 61.9% 


74.3% • 


67.5% 


66.9% 


70.5% * 


63.1% 


77.0% - 


20.8% 


20.4% 


19.9% 25.6% 


13.3% • 


18.5% 


16.8% 


17.0% 


23.0% 


11.2% • 


4.8% 


5.1% 


4.3% 4.4% 


3.9% 


4.7% 


4.7% 


3.9% 


3.9% 


2.9% 


8.1% 


10.2% 


8.4% 8.1% 


8.5% 


9.3% 


11.6% 


8.6% 


10.0% 


9.0% 



89.4% * 


85.3% 


87.0% 


87.0% " 


81.9% 


84.6% 


26.4% 


24.3% * 


26.1% 


16.5% 


17.4% 


18.2% 


6.9* 


6.1 


6.4 


5.0 


4.5 


4.7 


3.1 * 


3.3* 


3.2 


3.4* 


3.3* 


3.3 


2.9* 


2.1 


2.0 



12.2% 
3.1% 



8.5% 
47.0% 



15.2% 15.5% 
3.7% 3.3% 



85.5% 
82.2% 
29.1% 
18.4% 



6.0 
4.7 
2.5 
2.8 
1.9 



16.0% 

4.1% 



85.6% 
82.7% 
30.4% 
18.1% 



5.8 
4.4 
2.7 
3.1 
1.8 



15.9% 

3.4% 



92.6% (a) 89.2% (a) 90.8% (a) 90.8% (a) 89.4% (a) 

90.3% (a) 85.3% "(a) 87.8% (a) 88.5% (a) 85.2% * 

29.6% * 35.7% *(a) 34.5% '(a) 44.8% (a) 41.5% (a) 

20.5%- 21.3% *{a) 21.7% (a) 24.8% (a) 22.5% (a) 



6.9 
4.6 
3.3 
3.2 



6.7 (a) 6.5 

4.6 4.7 

3.7 * 3.1 
3.3 3.2 



2.2 "(a) 2.0 * 



14.3% 
3.3% 



14.9% 
3.6% 



2.1 * 



15.8% 
3.8% 



6.4 


6.1 


4.6 


4.4 


2.9 


2.9 


3.0 


2.9 


1.5 (a) 


2.5 



16.1% 

4.3% 



14.0% 
3.3% 



39.5% * 


39.1% ' 


41.6% 


44.3% 


41.8% 


47.3% 


37.7% 


38.4% 


41.9% 


34.2% 


56.5% 


46.8% 


48.0% 


50.1% 


48.8% 



9.1% 9.7% 

54.2% 54.8% 



8.3% 
44.2% 



11.1% 
58.9% 



93.7% 


94.2% 


95.0% 


95.5% 


94.1% 


93.8% 


94.1% 


94.4% 


94.1% 


94.8% 


90.5% * 


92.1% * 


92.9% * 


94.7% 


93.1% 


72.3% 


71.5% 


70.3% 


72.7% 


69.7% 



46.6% (a) 44.5% *(a) 49.6% (a) 49.9% (a) 47.0% 

38.9% (a) 33.6% 33.1% (a) 35.2% (a) 29.6% ' 

39.9% (a) 31.5% (a) 32.2% (a) 36.8% (a) 31.0% (a) 

6.7% 7.7% 7.4% (a) 6.4% (a) 8.5% 

47.8% 55.8% 57.4% 45.6% 65.1% ' 



94.9% 96.2% (a) 96.5% (a) 96.0% 96.1% (a) 

96.1% (a) 96.3% (a) 96.5% (a) 95.9% 97.0% (a) 

93.9% 93.6% 93.3% 94.9% 93.3% 

82.1% *(a) 80.9% (a) 79.2% (a) 78.4% (a) 77.4% (a) 



* Significantly different from those in areas with plus or minus 1 percent change in Medicare fees (p<0.05). 

(a) Significantly different overtime (1991 - 1992). 

Note: Age-adjusted using the direct method of standardization. 

Sources: Medicare Current Beneficiary Survey, Round 1 and Round 4 Data; Medicare NCH Claims for MCBS Population. 
Primary analysis by the Center for Health Economics Research. 



TABLE V-4 

ATTITUDES TOWARD THE USUAL SOURCE OF CARE, BY LEVEL OF 1992 MEDICARE FEE SCHEDULE CHANGE: 
1991 -1992 



All Plus or 

Med icare 5 to 11 % 3 to 5% 1 to 3% Min us 1 % 1 to 1 0% 

Beneficiaries Reduction Reduction Reduction Change Increase 



Doctor is Competent and Well-Trained 


1991 


98.5% 




98.4% 


98.2% 


98.8% 


98.9% 


98.0% 




1992 


98.8% 




98.4% 


98.9% 


98.8% 


98.4% 


99.1% (a 


Doctor Answers Ail Questions 


1991 


95.9% 




95.0% 


96.1% 


96.3% 


95.6% 


96.0% 




1992 


95.7% 




94.1% * 


95.7% 


96.3% 


96.3% 


95.3% 


Doctor Has Good Understanding 


1991 


95.3% 




93.2% 


96.0% 


95.8% 


94.2% 


95.7% 


of iViedical History 


1992 


95.9% 




94.1% 


96.6% 


96.1% 


95.3% 


96.2% 


Respondent has Great Confidence 


1991 


94.3% 




93.4% 


94.6% 


94.3% 


94.7% 


94.3% 


in Doctor 


1992 


94.2% 




93.9% 


95.8% * 


93.9% 


93.3% 


93.1% 


Doctor Understands Tilings That 


1991 


93.2% 




91.0% 


93.8% 


94.0% 


92.4% 


92.6% 


are Wrong 


1992 


94.1% 


(a) 


93.3% 


95.2% 


94.2% 


93.4% 


93.4% 


Doctor Checks Everything When 


1991 


92.7% 




92.3% 


93.2% 


93.0% 


92.4% 


92.1% 


Examining 


1992 


93.6% 




93.9% 


95.5% -(a) 


93.2% 


91.9% 


92.2% 


Doctor Tells All that Respondent 


1991 


91.1% 




89.9% 


92.0% 


91.2% 


91.2% 


90.2% 


Wants to Know 


1992 


91.1% 




89.9% * 


92.0% 


91.3% 


93.1% 


88.9% * 


Respondent Depends on Doctor 


1991 


85.7% 




84.8% 


85.5% 


85.4% 


84.3% 


88.8% * 


To Feel Better 


1992 


84.2% 




78.5% * 


85.0% 


84.0% 


84.3% 


87.8% * 


Doctor Seems to be in a Hurry 


1991 


18.5% 




19.9% 


18.5% 


17.2% 


17.3% 


21.1% * 




1992 


16.1% 


(a) 


16.8% 


14.0% *(a) 


15.8% 


17.2% 


19.1% 


Doctor Does Not Explain Medical 


1991 


15.7% 




17.8% 


15.6% 


15.1% 


14.7% 


16.4% 


Problems 


1992 


14.1% 




16.4% * 


12.8% 


13.5% 


12.4% 


16.5% * 


Doctor Does Not Discuss Health 


1991 


13.0% 




16.0% * 


12.5% 


12.1% 


11.8% 


13.9% 


Problems 


1992 


10.8% 


(a) 


12.2% 


10.6% 


10.4% (a) 


9.5% 


11.7% 


Doctor Acts as if Doing a Favor 


1991 


8.3% 




9.1% * 


8.0% 


7.4% 


6.5% 


11.4%* 




1992 


6.9% 


(a) 


7.4% 


6.6% 


6.5% 


6.1% 


8.5% * 



* Significantly different from those in areas with plus or minus 1 percent change in expected Medicare fees (p<0.05). 

(a j Significantly different over time (1 991 -1 992). 

Source: Medicare Current Beneficiary Survey, Round 1 and Round 4 Data; 
Primary analysis by the Center for Health Economics Research. 



TABLE V-5 

UTILIZATION, ACCESS, AND SATISFACTION INDICATORS, BY PERCEIVED HEALTH STATUS: 1991 - 1992 

1991 



Type of Regular Source 

Physician's office 

Other place with regular physician 

Other place with no regular physician 

None 

Physician Use 

Percent with: 

Physician visit (any setting) 
Physician visit in non-hospital setting 
Outpatient department visit 
Emergency room visit 

Average number of office visits per user 
Total 

To primary care physician 
To medical specialist 
To other specialist 
To non-physician 

Hospital Use 

Percent with hospitalization 
Percent with ACS condition 

Preventive Use 

Percent with flu shot in previous winter 
Percent of women with mammogram 

in previous year 
Percent of women writh Pap smear 

in previous year 

Barriers to Care 

Percent reporting a health problem and 

not receiving care in previous year 
Of those, percent reporting a 
financial barrier 

Satisfaction with Care 

Percent satisfied with: 
Quality of medical care 
Availability of medical care 
Ease of getting to doctor 
Costs of medical care 



Very 
Excellent Good 



Good 



Fair 



Poor 



63.5% 66.4% 68.8% * 68.5% * 66.1% 

18.7% 20.0% 19.6% 19.4% 22.1% 

4.3% 4.3% 3.9% 5.4% 5.8% 

13.5% 9.3% 7.8% 6.8% * 5.9% 



76.1% 

73.6% 

19.2% 

9.6% 



4.5 
3.3 
2.6 
2.8 
2.2 



7.6% 
0.7% 



83.1% 
80.3% 
23.5% 
14.0% 



5.3 
3.9 
2.8 
2.9 
2.1 



10.5% 
1.6% 



88.7% * 91.1% * 94.2% 
86.2% • 87.8% • 91.0% 
27.2% • 31.8% • 36.5% 
17.3% * 23.9% • 32.9% 



6.5 * 
4.7 • 
3.0 
3.3 * 
2.0 



7.5 
5.6 
3.4 
3.7 
2.3 



14.6% * 20.9% 
3.0% * 5.1% 



8.9 
6.5 
4.0 
4.1 
2.5 



31.9% 
12.6% 



36.7% 40.4% * 41.7% * 42.0% ' 43.6% 

39.9% 43.5% 35.6% * 38.4% 33.1% 

49.3% 52.1% 46.6% 49.2% 38.7% 

3.6% 5.7% * 8.6% * 14.6% * 22.7% 

70.1% 47.9% * 51.2% * 52.3% * 60.1% 



97.7% 95.8% * 95.9% * 92.8% * 84.6% 

96.7% 95.0% • 94.9% ' 93.2% * 904% 

95.9% 95.1% 93.4% * 90.0% * 83.4% 

81.1% 76.1% * 70.6% * 64.8% * 53.6% 







1992 








Very 








Excellent 


Good 


Good 


Fair 


Poor 


65.0% 


69.1% " 


70.7% * 


71.7% * 


69.9% * 


16.8% 


16.7% 


17.0% 


16.9% 


17.0% 


3.4% 


3.5% 


4.1% 


4.5% 


6.4% 


14.8% 


10.8% 


8.3% * 


6.9% * 


6.8% * 



81.6% (a) 87.6% *(a) 93.0% *(a) 95.4% *(a) 94.3% * 

78.6% (a) 84.5% *(a) 90.3% '(a) 91.8% *(a) 88.1% * 

28.1% (a) 32.0% *(a) 37.2% '(a) 44.1% *(a) 46.4% '(a) 

11.3% 16.8% *(a) 21.2% *(a) 30.9% '(a) 44.6% *(a) 



4.7 
3.3 
2.6 
2.8 

1-6 (a) 



8.0% 
1.4% 



5.6 * 

3.9* 

3.0 

2.8 

2.3* 



9.8% 
2.0% 



6.5 
4.6 
3.1 
3.2 
1.9 



15.7% * 
3.2% * 



8.2 *(a) 9.2 

5.7 * 6.4 

4.1 -(a) 3.8 

3.6 * 3.9 

2.7 * 2.2 



21.4% * 
6.5% * 



33.3% 
9.3% 



43.5% (a) 47.9% *(a) 47.0% *(a) 48.7% *(a) 51 .9% '(a) 

32.1% (a) 37.0% *(a) 32.6% 33.3% (a) 25.4% * 

31.9% (a) 34.7% (a) 35.1% (a) 31.0% (a) 28.4% (a) 

2.9% 3.9% (a) 6.5% *(a) 12.6% * 20.1% * 

69.5% 59.2% 53.2% * 51.9% * 59.8% 



97.8% 98.2% (a) 96.6% * 94.1% * 87.8% * 

98.4% (a) 97.2% '(a) 96.8% *(a) 95.5% *(a) 90.9% * 

96.4% 95.9% 93.5% * 91.3% * 85.6% * 

87.8% (a) 84.8% *(a) 79.0% *(a) 73.6% *(a) 64.4% "(a) 



* Significantly diflerent from those with excellent health (p<0.05). 

(a) Signilicantly different overtime (1991- 1992). 

Note: Age-adjusted using the drect method of standardization. 

Sources: Medicare Current Beneficiary Sirvey. Round 1 and Round 4 Data: Medicare NCH Qaims for MCBS Population. 
Primary analysis by the Center for Health Economics Research. 



TABLE V-6 

UTILIZATION, ACCESS, AND SATISFACTION INDICATORS, BY INCOME: 1991 - 1992 



1991 



1992 



Type of Regular Source 

Physician's office 

Other place with regular physician 

Other place with no regular physician 

None 

Physician Use 

Percent with: 

Physician visit (any setting) 
Physician visit in non-hospital setting 
Outpatient department visit 
Emergency room visit 

Average number of office visits per user. 
Total 

To primary care physician 
To medical specialist 
To other specialist 
To non-physician 

Hospital Use 

Percent with hospitalization 
Percent with ACS condition 



$10,000 


$10,001 


$20,001 


$35,001 


$10,000 


$10,001 


$20,001 


$35,001 


or Less 


to $20,000 to $35,000 


or More 


or Less 


to $20,000 


to $35,000 


or More 


63.7% * 


67.1% 


68.0% 


712% 


68.3% • 


69.9% 


692% 


73.9% 


19.0% 


21.1% 


20.7% 


17.7% 


16.4% 


17.0% 


19.0% 


15.4% 


6.4% 


4.0% 


3.7% 


4.1% 


4.9% 


3.3% 


3.4% 


3.7% 


11.0% 


7.9% 


7.7% 


7.0% 


10.5% 


9.8% 


8.5% 


7.1% 



83.1% * 


86.7% 


892% 


88.9% 


88.6% '(a) 


91.2% 


*(a) 


92.4% *(a) 


95.0% 


(a) 


79.9% • 


83.8% 


86.4% 


86.3% 


84.7% *(a) 


88.3% 


*{a) 


89.9% (a) 


91.8% 


(a) 


252% 


28.0% 


282% 


28.5% 


34.0% *(a) 


37.8% 


(a) 


39.0% (a) 


40.1% 


(a) 


21.4% * 


17.3% 


16.8% 


15.8% 


23.4% * 


21.6% 


(a) 


21.6% (a) 


18.3% 




6.7 • 


6.3* 


6.1 


5.7 


6.7* 


6.5 




6.4 


6.1 




52 * 


4.7* 


4.4* 


3.7 


4.9 *(a) 


4.5 


* 


4.5* 


3.6 




3.5 


3.0 


3.0 


3.0 


3.4 


3.1 




3.0 


3.3 




3.4 


3.3 


3.0 


3.1 


32 


32 




2.9* 


3.4 




1.9 


2.1 


22 


22 


2.0 


2.0 




2.4 


2.1 




16.7% • 


15.5% 


142% 


13.1% 


162% 


14.9% 




12.7% 


14.5% 




4.6% • 


3.3% 


2.8% 


2.7% 


4.0% * 


3.4% 




3.5% 


2.1% 





Preventive Use 

Percent with flu shot in previous winter 32.3% * 

Percent of women with mammogram 

in previous year 31.1%* 

Percent of vramen with Pap smear 

in previous year 39.6% * 

Barriers to Care 

Percent reporting a health problem and 15.0% * 

not receiving care in previous year 
Of those, percent reporting a financial barrier 59.7% * 

Satisfaction with Care 

Percent satisfied with: 

Quality of medical care 92.8% * 

Availability of medical care 94.4% 

Ease of getting to doctor 88.6% * 

Costs of medical care 67.0% * 



42.0% * 46.7% * 51.6% 

39.4% * 45.9% * 54.3% 

51.5% * 57.6% 61.1% 

9.8% * 6.8% * 4.4% 

48.5% 42.7% 33.7% 



94.5% * 95.8% 96.6% 

94.0% 94.9% 93.7% 

92.9% * 95.6% 95.1% 

68.3% * 74.9% 77.5% 



42.4% *(a) 


47.7% *(a) 


56.4% 


(a) 


60.9% 


(a) 


30.4% * 


33.8% *(a) 


41.8% 




47.8% 




30.5% *(a) 


33.3% *(a) 


40.0% 


(a) 


47.0% 


(a) 


8.8% *(a) 


7.3% *(a) 


6.1% 




52% 




63.3% * 


53.8% * 


39.4% 




34.5% 





95.4% *(a) 
96.6% (a) 
92.7% *(a) 
78.4% *(a) 



96.1% *(a) 
95.8% (a) 
93.5% * 
79.0% *(a) 



96.5% * 982% 

96.5% (a) 96.7% (a) 

95.1% 95.9% 

81.9% (a) 83.7% (a) 



* Sigilticantly dfferent from those wflh incomes over $35,000 (p<0.05). 

(a) Si gnificantlydfrerent over lime (1991 -1992). 

Note: Age-ac^usted using the drect method of standartSzation. 

Soirees: Med care Curent Benefidary Sirvey. Round 1 and Romd 4 Data: Medcare NCH Claims for MCBS PopiJalioa 
Primary analysis by the Center for Heaith Economics Research. 



TABLE V- 7 

UTILIZATION. ACCESS, AND SATISFACTION INDICATORS, BY SUPPLEMENTAL INSURANCE COVERAGE: 1991-1992 



1991 



1992 



Type of Regular Source 

Physician's office 

Other place with regular physician 

Other place wfth no regular physician 

None 

Physician Use 

Percent with: 

Physician visit (any setting) 
Physician visit In non-hospital setting 
Outpatient department visit 
Emergency room visit 

Average number of office visits per user 
Total 

To primary care physician 
To medical specialist 
To other specialist 
To non-physician 

Hospital Use 

Percent with hospitalization 
Percent with ACS condition 

Preventive Use 

Percent with flu shot In previous winter 
Percent of women wHh mammogram 

in previous year 
Percent of women with Pap smear 

in previous year 

Barriers to Care 

Percent reporting a health problem and 

not receiving care In previous year 
Of those, percent reporting a 
financial barrier 

Satisfaction with Care 

Percent satisHed with: 
Quality of medical care 
Availability of medical care 
Ease of getting to doctor 
Costs of medical care 





Medicare 


Medicare 


Medicare 




!\^edlcare 


Medicare 


Medicare 


Medicare 


and 


and 


and 


Medicare 


and 


and 


and 


Only 


Medicaid 


Private 


aher 


Only 


Medicaid 


Private 


Other 


49.7% * 


62.8% * 


70.5% 


65.1% • 


50.2% * 


66.7% * 


72.4% 


68.1% * 


19.4% 


20.3% 


19.4% 


23.3% 


15.1% 


16.7% 


16.8% 


19.6% 


11.0% * 


7.7% 


3.0% 


5.5% 


11.5% * 


5.7% 


2.7% 


5.5% 


19.9% * 


9.2% 


7.1% 


6.2% 


23.2% * 


10.9% 


8.1% 


6.8% 



73.1% * 


88.0% 


88.2% 


90.4% 


75.8% ' 


91.7% 




91.9% (a) 


92.8% 


66.9% * 


84.3% 


86.1% 


86.0% 


68.3% * 


86.1% 


• 


89.7% 


(a) 


87.8% 


25.6% 


25.9% 


26.7% 


29.4% 


30.6% *(a) 


33.9% 


*(a) 


37.2% 


(a) 


38.6% (a) 


17.7% 


25.1% • 


16.6% 


25.3% • 


20.1% 


34.5% 


*(a) 


19.8% 


(a) 


32.0% *(a) 


5.1 • 


8.2 * 


6.1 


7.6* 


5.4 * 


8.4 


. 


6.3 




7.2 * 


4.4 


6.2* 


4.4 


5.5* 


4.4 


6.2 


* 


4.4 




5.3* 


2.9 


4.1 * 


2.9 


3.2 


2.9 


4.2 


* 


3.2 




3.3 


2.8 


4.2 * 


3.1 


4.0* 


3.1 


3.8 


■ 


3.1 




3.5* 


2.2 


1.8 • 


2.3 


1.6* 


1.6* 


2.1 




2.1 




1.9 


11.1% * 


22.6% * 


14.5% 


23.2% • 


12.5% 


22.4% 


• 


14.3% 




17.7% *(a) 


2.9% 


6.3% * 


3.1% 


7.2% • 


3.8% 


5.1% 


• 


3.3% 




4.7% 


25.5% * 


29.4% * 


44.2% 


42.3% 


29.4% * 


35.0% 


• 


50.6% 


(a) 


48.5% 


22.3% * 


32.0% * 


42.1% 


38.9% 


18.5% * 


23.2% 


*(a) 


36.9% 


(a) 


30.3% *(a) 


29.6% * 


38.7% * 


53.4% 


40.4% * 


13.9% *(a) 


22.5% 


•(a) 


37.2% 


(a) 


29.6% *(a) 



14.5% 
63.9% 



17.5% 
51.2% 



7.9% 
50.7% 



12.0% 
58.4% 



13.4% * 
81.9% *(a) 



93.0% * 


93.8% 


94.9% 


91.4% * 


93.9% * 


94.5% 


95.4% 


94.1% 


94.0% 


96.6% 


90.7% * 


84.6% * 


93.9% 


90.4% * 


90.3% * 


63.8% * 


80.2% * 


70.8% 


69.9% 


70.6% *(a) 



10.4% *(a) 6.3% (a) 7.8% (a) 
62.1% * 49.7% 59.5% 



94.5% * 96.7% (a) 94.4% * 

95.8% 96.4% (a) 96.4% 

88.6% * 94.5% 91.9% * 

88.1% *(a) 79.4% (a) 80.5% (a) 



• Significantly afferent from ttiose with Medicare and private insurance (p<0.05). 

(a) Signiticantfy different over time (1991 - 1992). 

Note: Age-a(^usted using the direct method of standardzatlon. 

Sources: Med care Current Beneficiary Survey, Round 1 and Romd 4 Data: Medicare NCI-I Claims for MCBS Population. 
Primary analysis by the Center for Health Econotnlcs Research. 



TABLE V-8 

DETERMINANTS OF UTILIZATION AND SATISFACTION IN THE NONINSTITLmONALIZED MEDICARE POPULATION, 1991 AND 1992: 
(Standard Errors In Parentheses) 



LOGISTIC REGRESSION 



WLS 



MEDICARE PAYMENT 
CHANGE VARIABLES 



Year 1992 



(Year 1991 Omitted) 

Medicare Payment Change (19921 

-1 1 to -5 Percent 



-5 to -3 Percent 
-3 to -1 Percent 
1 to 10 Percent 



-1 to +1 Percent (Omitted) 

Interaction of Year 1992*Medicare 
Payment Change 

-1 1 to -5 Percent 



-5 to -3 Percent 
-3 to -1 Percent 

1 to 10 Percent 

-1 to +1 Percent (Omitted) 
OTHER VARIABLES 
Age 

Age Squared 

Sex 

Male 

(Female omitted) 
RaceJEthnicity 

Black 

Hispanic 

Other 



Any Physician Visit OPD Visit 



0.76 (a) 
(0.13) 



0.77 (a) 
(0.08) 



ER Visit 



0.38 (a) 
(0.10) 



Satisfied wtth 
Inpatient Stay Cost 



Number of Office 
Satisfied with Visits/Consultations Per 



0.09 
(0.11) 



0.31 (a) 
(0.12) 



Availability 



0.35 
(0.29) 



User 



0.34 
(0.25) 



0.31 (c) 
(0.16) 


0.02 
(0.17) 


-0.19 
(0.15) 


-0.30 (b) 
(0.15) 


-0.14 
(0.11) 


-0.22 
(0.26) 


0.52 
(0.44) 


0.04 
(0.12) 


-0.13 
(0.15) 


-0.16 
(0.13) 


0.02 
(0.13) 


-0.14 
(0.10) 


-0.23 
(0.20) 


0.04 
(0.31) 


0.03 
(0.12) 


-0.11 
(0.14) 


-0.08 
(0.12) 


-0.03 
(0.10) 


-0.12 
(0.10) 


0.06 
(0.20) 


0.13 
(0.29) 


0.07 
(0.13) 


0.21 
(0.15) 


-0.09 
(0.14) 


-0.04 
(0.14) 


-0.11 
(0.12) 


0.17 
(0.24) 


-0.10 
(0.41) 



-.13 
(.23) 


-.55 (a) 
(.11) 


-.07 
(.14) 


.19 
(.16) 


.31 (b) 
(.14) 


.20 
(.37) 


-.25 
(.34) 


-.19 
(.18) 


-.15 
(.11) 


-.10 
(.15) 


-.09 
(.14) 


.24 (c) 
(.14) 


.14 
(.34) 


.12 

(.27) 


-.17 
(.16) 


-.32 (a) 
(.10) 


-.14 
(.12) 


-.04 
(.14) 


.20 
(.15) 


.06 
(.32) 


-.27 
(.27) 


-.28 
(.20) 


-.21 (c) 
(.13) 


-.05 
(.13) 


-.13 
(.17) 


.07 
(.14) 


.13 

(.37) 


-.07 
(.32) 



-0.04 (a) 
(0.02) 


0.02 (a) 
(0.01) 


-0.08 (a) 
(0.01) 


-0.04 (a) 
(0.01) 


-0.01 
(0.01) 


0.04 ( 
(0.02) 


(b) 


0.14 (a) 
(0.03) 


0.0004 (a) 
(0.0001) 


-0.0002 (a) 
(0.0001) 


0.0006 (a) 
(0.0001) 


0.0004 (a) 
(0.0001) 


0.0002 (b) 
(0.0001) 


-0.0002 
(0.0001) 




-0.0007 (a) 
(0.0003) 


-0.27 (a) 
(0.06) 


-0.04 
(0.05) 


0.13 (b) 
(0.05) 


0.27 (a) 
(0.06) 


0.12 (b) 
(0.05) 


0.03 
(0.10) 




-0.14 
(0.13) 



0.12 
(0.15) 


0.09 
(0.09) 


0.26 
(0.09) 


(a) 


-0.17 (c) 
(0.09) 


-0.08 
(0.09) 


0.09 
(0.14) 


0.04 
(0.24) 


-0.27 
(0.19) 


-0.08 
(0.12) 


-0.02 
(0.10) 




-0.14 
(0.12) 


0.19 (c) 
(0.11) 


0.09 
(0.20) 


0.69 (c) 
(0.41) 


0.28 
(0.23) 


-0.03 
(0.16) 


-0.06 
(0.22) 




-0.54 (b) 
(0.21) 


-0.08 
(0.18) 


-0.35 
(0.29) 


0.25 
(0.71) 



(White omitted) 



TABLES V-8 (Continued) 

DETERMINANTS OF UTILIZATION AND SATISFACTION IN THE NONINSTITUTIONALIZED MEDICARE POPULATION, 1991 AND 1992 
(Standard Errors in Parentheses) 



LOGISTIC REGRESSION 



WLS 



Educational Status 

Less than 12 years 

12 years 

(More than 12 years omitted) 
Living Arrangement 

Living with others 

Living alone 

(Living with spouse omitted) 

Living Children 

Yes 

(No living children omitted) 
Income Status 

SI 0,000 or less 

$10,001 to $20,000 

$20,001 to $35,000 

($35,001 and above omitted) 
Supplemental Coverage 

Medicaid 

Private 

Other or Combination 

(No supplemental coverage omitted) 
Regular Source of Care 

Physician's office 

Other place with regular physician 
Other place without regular physician 
(No regular source omitted) 















Number of Office 










Satisfied with 


Satisfied with 


VisitsfConsultations Per 


Anv Physician Visit 


OPD Visit 


ER Visit 


Inpatient Stay 


Cost 


Availability 


User 


-0.37 (a) 
(0.10) 


-0.30 (a) 
(0.06) 


0.03 
(0.06) 


-0.12 (c) 
(0.07) 


0.06 
(0.07) 


0.61 (a) 
(0.12) 


-0.29 
(0.21) 


-0.24 (a) 
(0.09) 


-0.16 (a) 
(0.06) 


-0.08 
(0.07) 


-0.14 (c) 
(0.07) 


0.11 
(0.07) 


0.41 (a) 
(0.11) 


-0.12 
(0.18) 



-0.21 (b) 
(0.10) 


-0.01 
(0.08) 


0.13 (b) 
(0.07) 


0.12 
(0.07) 


0.10 
(0.07) 


0.16 
(0.12) 


-0.26 
(0.19) 


0.06 
(0.09) 


0.01 
(0.06) 


0.22 (a) 
(0.05) 


0.18 (a) 
(0.06) 


0.15 (a) 
(0.06) 


0.14 
(0.12) 


0.27 (c) 
(0.16) 



0.19 (b) 


0.06 


0.17 (a) 


0.19 (a) 


-0.26 (a) 


-0.15 


-0.03 


(0.09) 


(0.06) 


(0.06) 


(0,07) 


(0.07) 


(0.13) 


(0.18) 



-0.67 (a) 
(0.13) 


-0.30 (a) 
(0.09) 


-0.08 
(0.10) 


-0.02 
(0.11) 


-0.52 (a) 
(0.09) 


0.10 
(0.17) 


0.09 
(0.19) 


-0.39 (a) 
(0.14) 


-0.13 
(0.08) 


-0.07 
(0.10) 


-0.01 
(0.11) 


-0.38 (a) 
(0.07) 


0.05 
(0.16) 


0.26 
(0.18) 


-0.19 
(0.14) 


-0.10 
(0.08) 


0.02 
(0.10) 


-0.05 
(0.11) 


-0.15 (c) 
(0.09) 


0.23 
(0.16) 


0.35 (c) 
(0.19) 



0.71 (a) 
(0.14) 


0.05 
(0.09) 


0.41 (a) 
(0.09) 


0.56 (a) 
(0.11) 


1.37 (a) 
(0.12) 


0.02 
(0.16) 


240 (a) 
(0.24) 


0.61 (a) 
(0.10) 


0.09 
(0.06) 


0.11 
(0.08) 


0.29 (a) 
(0.10) 


0.30 (a) 
(0.08) 


-0.17 
(0.13) 


1.07 (a) 
(0.21) 


0.74 (a) 
(0.16) 


0.17 (b) 
(0.09) 


0.47 (a) 
(0.11) 


0.38 (a) 
(0.12) 


0.52 (a) 
(0.12) 


-0.05 
(0.23) 


1.64 (a) 
(0.34) 



225 (a) 
(0.10) 


0.86 (a) 
(0.09) 


0.52 (a) 
(0.11) 


0.67 (a) 
(0.12) 


-0.28 (a) 
(0.08) 


0.23 
(0.15) 


1.92 (a) 
(0.22) 


244 (a) 
(0.13) 


1.16 (a) 
(0.09) 


0.57 (a) 
(0.12) 


0.51 (a) 
(0.13) 


-0.08 
(0.09) 


0.11 
(0.19) 


1.28 (a) 
(0.23) 


1.10 (a) 
(0.15) 


1.41 (a) 
(0.12) 


0.62 (a) 
(0.13) 


-0.04 
(0.17) 


0.21 (c) 
(0.12) 


-0.32 
(0.23) 


-0.21 
(0.33) 



TABLE V-8 (Continued) 

DETERMINANTS OF UTILIZATION AND SATISFACTION IN THE NONINSTITUTIONALIZED MEDICARE POPULATION. 1991 AND 1992 
(Standard Errors In Parentheses) 



JUMB" 



LOGISTIC REGRESSION 



WLS 



Physicians Per Capita 

Perceived Health Status 

Very Good 

Good 

Fair 

Poor 

(Excellent health status omitted) 
Level of Dependency 

lADL only 

1-2ADLS 

3-4ADLS 

S^ADLs 

(No ADL/IADL omitted) 
Geographic Location 

New England 

Middle Atlantic 

East North Central 

West North Central 

South Atlantic 

East South Central 

West South Central 

Mountain 

(Pacific omitted) 
Urban 















Number of Office 










Satisfied with 


Satisfied with 


Visits/Consultations Per 


Any Physician Visit 


OPD Visit 


ER Visit 


Inpatient Stay 


Cost 


Availability 


User 


0.35 
(0.33) 


0.78 (a) 
(0.25) 


-0.54 (b) 
(0.23) 


0.20 
(0.22) 


-0.45 (c) 
(0.23) 


0.64 
(0.42) 


1.38 (c) 
(0.71) 


0.45 (a) 
(0.08) 


0.23 (a) 
(0.07) 


0.40 (a) 
(0.08) 


0.26 (a) 
(0.10) 


-0.24 (a) 
(0.07) 


-0.42 (a) 
(0.14) 


0.78 (a) 
(0.13) 


1.02 (a) 
(0.08) 


0.44 (a) 
(0.06) 


0.60 (a) 
(0.08) 


0.64 (a) 
(0.09) 


-0.50 (a) 
(0.07) 


-0.47 (a) 
(0.16) 


1.74 (a) 
(0.16) 


1.33 (a) 
(0.10) 


0.72 (a) 
(0.07) 


0.96 (a) 
(0.08) 


0.91 (a) 
(0.10) 


-0.70 (a) 
(0.09) 


-0.71 (a) 
(0.15) 


3.05 (a) 
(0.19) 


1.58 (a) 
(0.16) 


0.90 (a) 
(0.10) 


1.35 (a) 
(0.10) 


1.32 (a) 
(0.10) 


-1.09 (a) 
(0.10) 


-1.23 (a) 
(0.16) 


4.02 (a) 
(0.27) 



0.28 (a) 
(0.12) 


0.05 
(0.08) 


0.19 (b) 
(0.08) 


0.35 (a) 
(0.08) 


-0.10 
(0.09) 


-0.50 (a) 
(0.14) 


0.44 (b) 
(0.21) 


0.30 (a) 
(0.07) 


0.09 (c) 
(0.05) 


0.27 (a) 
(0.06) 


0.37 (a) 
(0.07) 


-0.32 (a) 
(0.06) 


-0.43 (a) 
(0.10) 


0.57 (a) 
(0.15) 


0.69 (a) 
(0.13) 


0.16 (b) 
(0.07) 


0.49 (a) 
(0.07) 


0.63 (a) 
(0.09) 


-0.60 (a) 
(0.07) 


-0.65 (a) 
(0.14) 


0.62 (b) 
(0.24) 


0.59 (a) 
(0.19) 


0.16 
(0.11) 


0.71 (a) 
(0.10) 


0.89 (a) 
(0.11) 


-0.53 (a) 
(0.12) 


-0.75 (a) 
(0.17) 


-0.14 
(0.31) 



0.27 
(0.22) 


0.23 
(0.14) 


0.22 
(019) 


0.02 
(0.15) 


0.09 
(0.20) 


0.06 
(0.28) 


-1.80 (a) 
(0.53) 


-0.02 
(0.15) 


0.15 
(0.11) 


-0.16 (c) 
(0.09) 


0.11 
(0.11) 


-0.09 
(0.11) 


-0.36 (b) 
(0.17) 


-0.90 (a) 
(0.35) 


-0.19 
(0.14) 


0.27 (b) 
(0.11) 


-0.13 
(0.09) 


0.02 
(0.11) 


-0.07 
(0.10) 


0.23 
(0.15) 


-1.56 (a) 
(0.35) 


-0.05 
(0.19) 


-0.25 
(0.24) 


-0.36 (a) 
(0.09) 


-0.03 
(0.17) 


0.04 
(0.17) 


0.15 
(0.38) 


-ZOO (a) 
(0.40) 


0.17 
(0.13) 


0.01 
(0.09) 


-0.22 (b) 
(0.09) 


-0.12 
(Oil) 


-0.11 
(0.10) 


-0.05 
(0.16) 


-1.40 (a) 
(0.41) 


-0.36 (a) 
(0.14) 


-0.29 (b) 
(0.12) 


-0.22 
(0.13) 


0.10 
(0.11) 


0.25 (b) 
(0.12) 


0.61 (a) 
(0.17) 


-1.80 (a) 
(0.44) 


-0.12 
(0.13) 


-0.11 
(0.12) 


-0.19 (b) 
(0.09) 


-0.11 
(0.11) 


-0.14 
(0.12) 


-0.24 
(0.20) 


-1.99 (a) 
(0.39) 


0.05 
(0.21) 


0.01 
(0.14) 


0.21 (b) 
(0.11) 


0.01 
(0.15) 


-0.12 
(0.20) 


0.01 
(0.17) 


-1.40 (b) 
(0.67) 


0.12 

(0.09) 


-0.17 
(0.11) 


0.11 
(0.09) 


-0.09 
(0.08) 


0.07 
(0.09) 


0.32 (c) 
(0.18) 


0.15 
(0.19) 



TABLE V-8 (Continued) 

DETERMINANTS OF UTILIZATION AND SATISFACTION IN THE NONINSTITUTIONAUZED MEDICARE POPULATION, 1991 AND 1992: 
(Standard Errors in Parentheses) 



LOGISTIC REGRESSION 



WLS 



(Rural omitted) 
Intercept 

R-squared 

N 

Minus log-likelihood 



Satisfied with 



Any Physician 


Visit 


OPD Visit 


ER Visit 


Inoatient Stay 


Cost 




Availability 


0.04 




-261 (a) 


-0.45 


-267 


(a) 


1.67 


(a) 


0.83 


(0.51) 




(0.39) 


(0.43) 


(0.50) 




(0.38) 




(0.70) 


0.19 




0.06 


0.07 


0.06 




0.07 




0.03 


16,424 




16,460 


16.476 


16,492 




16,415 




16,436 


4,679 




9.805 


7.698 


6,288 




8,528 




2,902 



Number of Office 
Satisfied with Visits/Consultations Per 
User 



-3.92 (a) 
(1.14) 



0.10 
12170 



(a)Significant at 0.01 level. 
(b)Significant at 0.05 level. 
(c)Significant at 0. 1 level. 



Source: Medicare Current Beneficiary Survey, Rounds 1 and 4 Data; Primary analysis by the Center for Health Economics Research. 



TABLE V-9 

PREDICTED PROBABILITY OF USE AND SATISFACTION BY LEVEL OF MEDICARE FEE SCHEDULE 
PAYMENT CHANGE 



Medicare Fee Schedule 
Payment Change, 1992 



-1 1 to -5 Percent 
-5 to -3 Percent 
-3 to -1 Percent 
-1 to +1 Percent 
1 to 10 Percent 



Outpatient Department Visit 









Percent 




1991 


1992 




Chanqe 


Significance Level 


27.9 % 


32.6 


% 


16.8 % 


(a) 


25.0 


38.3 




53.2 




25.3 


34.8 




37.5 


(a) 


27.4 


45.0 




64.2 




31.9 


45.1 




41.4 


(c) 



Medicare Fee Schedule 
Payment Change, 1992 



Satisfaction with Cost 













Percent 






1991 




1992 




Change 


Significance Level 


-1 1 to -5 Percent 


72.2 


% 


82.8 


% 


14.7 % 


(b) 


-5 to -3 Percent 


72.1 




81.7 




13.3 


(c) 


-3 to -1 Percent 


72.5 




81.4 




12.3 




-1 to +1 Percent 


74.9 




80.3 




7.2 




1 to 10 Percent 


72.8 




79.7 




9.5 





(a)Significantly different at .01 level. 
(b)Significantly different at .05 level. 
(c)Significantly different at .10 level. 



montana\cbs\TABLE9.XLS\sjb 



Appendix VI 

A Baseline Analysis of Utilization and Access From The National 
Health Interview Survey, 1984-1991 



Prepared by: Renee M. Mentnech 
Office of Research and Demonstrations 
Health Care Financing Administration 

April 1994 

Revised May 31, 1994 



Appendix VI 

A Baseline Analysis of Utilization and Access From The National 
Health Interview Survey, 1984-1991 



INTRODUCTION 

This appendix presents information from the National Health Interview Survey (NHIS). 
The NHIS, an annual household survey of the non-institutionalized U.S. population, 
collects health status, utilization, and socioeconomic infoimation that can be used to 
understand and monitor trends in access to health care. Use of physician services can 
be analyzed by important variables such as insurance status, income, and health status, 
making the NHIS a valuable data source for evaluating the effects of physician payment 
reform on access. Because the NHIS collects information on persons of all ages, it 
permits the comparison of the elderly with the non-elderly. Such a comparison aids in 
the determination of whether changes are limited to the aged or reflect overall national 
trends. 

The 1993 report presented descriptive data for 1984, 1986, 1989, and 1990 on trends in 
use of physician services by health status and sociodemographic categories, as well as a 
multivariate analysis of the trends in use of physician services for the 1984, 1986, and 
1989 time period. This report updates the pre-physician payment reform descriptive 
data with information from the 1991 NHIS and updates the multivariate analysis vdth 
data from the 1990 NHIS. As more data become available, the analyses in this 
appendix will be expanded and changes in the use of physician services for vulnerable 
groups will be tracked for years when physician payment reform has been in effect. 

METHODS 

Data from the NHIS conducted in 1984, 1986, 1989, 1990, and 1991 are used in this 
appendix because these years had supplemental questions on health insurance coverage. 
Approximately 41,000 households were interviewed in 1984; 25,000 in 1986; 48,000 in 
1989; 49,000 in 1990; and 49,000 in 1991. The supplemental questions on health 
insurance status in the 1991 NHIS were not available in time for this report. Data on 
health insurance status and income from the 1991 through 1994 surveys, however, will 
be used in future reports as they become available. 

In this analysis, physician use is examined by sociodemographic characteristics, health 
status, and geographic area (see Endnotes for definitions and additional information 
about the NHIS). Use of physician services includes telephone contacts with a 



Appendix VI- 1 



physician as well as contacts made in person; it does not include contacts while an 
overnight patient in the hospital. Because the vast majority (about 90 percent) of 
physician contacts are in person, the term visit will be used rather than contact (it 
should be noted that contacts in the NHIS also include visits to other than medical 
doctors). 

The focus of the analysis is on vulnerable segments of the Medicare population: persons 
with low income; Medicare enroUees without any supplemental health insurance; 
Medicare enrollees also entitled to Medicaid; persons in self-reported poor health, or 
persons with chronic conditions or activity limitations; racial minorities; and persons 
residing in rural areas. Use rates by vulnerable segments of the population are 
measured in several ways: 1) the percent of persons with at least one physician visit in 
a year; 2) the mean number of visits per person per year; and 3) the proportion of 
physician visits in a year occurring in physicians' offices. Comparisons of these 
utilization measures are made across population groups. The percent change in use of 
physician services as measured by the NHIS non-institutionalized population between 
1984 and 1991 is presented. When the phrase "use of physician services" is used in the 
text, it refers to both the percent of persons with a visit and the mean visit rate. 

Unless otherwfse noted, for the descriptive data, all estimates in this report have 
relative standard errors (the standard error divided by the estimate) of 15 percent or 
less. These relative standard errors were calculated using the SUDAAN software 
package; this software package accounts for the complex samphng design of the NHIS 
in deriving the relative standard errors. Unless otherwise noted, the differences 
discussed in the text are significant at the .05 level using the Z test. 

To investigate the independent effects of particular variables on use of physician 
services while controlling for possible covariates, a multivariate analysis of the 1984- 
1990 data was conducted using a two-part model. The first part used logistic regression 
to explore the effect of a range of sociodemographic and health status variables on the 
probability of having at least one physician visit. The second used ordinary least 
squares to explore the relation between the same independent variables and the 
number of visits per users for persons with at least one visit. To determine whether 
there was a trend in use of physician services, the stability of the regression coefiHcients 
over time was evaluated. The stability of the coefficients was evaluated through pair- 
wise comparisons of individual coefficients from one year to the next. The null 
hypothesis is that for a particular variable the coefficient has not changed from one 
year to the next. If the difference between the coefficients for a particular variable is 
significant, then this suggests that the effect of that variable on physician use has 
increased or decreased. 



Appendix VI-2 



DESCRIPTIVE RESULTS 

Percent change in physician visit rates, 1984-1991 

Throughout the 1984-1991 time period use of physician services was higher for persons 
65 years of age and over than for persons 18-64 years of age (Table VI-1). Likewise, 
persons 75 and over used shghtly more physician services than persons 65-74 years of 
age. For the elderly, an increase in the percent of persons with a visit was observed 
throughout the study period, with most of this increase occurring between 1986 and 
1989. In 1984, 82 percent of the elderly had a physician visit; by 1991, 86 percent of 
the elderly had a physician visit. Since 1984, the mean visit rate increased substantially, 

26.7 percent, for the elderly to a rate of 10.4 visits per person in 1991, and by 9.2 
percent for the non-elderly to a rate of 5.4 visits per person. Much of the increase for 
the elderly occurred between 1990 and 1991. Since the percent of elderly with a visit 
remained constant between 1990 and 1991, the increase in the visit rate is attributable 
to an increase in use among users, particularly for the population 75 years of age and 
over. 

Use of physician services and health status 

As described previously (Health Care Financing Administration, 1992 and 1993), for all 
three health status measures (self-reported health status, activity limitation, and 
presence of a chronic condition), use of physician services was highest for persons 
reporting the poorest health (Table VI-2). In 1991, 81 percent of elderly persons in 
excellent/very good health had a physician visit compared with 92 percent of persons in 
fair/poor health. Similarly, the mean visit rate was 6.1 for elderly persons in 
exceUent/veiy good health and 17.9 for elderly persons in fair/poor health. 

In each of the study years and for both age groups, persons with the most severe 
activity limitation had a much higher mean visit rate than those without a limitation. 
Among persons 65 years of age and over, the mean visit rate in 1991 was about 

26.8 visits per person for those unable to perform their major activity, versus 6.5 for 
those without an activity limitation. 

A significant increase in the percent of elderly persons with a visit was observed 
between 1984 and 1991 for most health status and activity limitation groups. Virtually 
all of this increase occurred prior to 1989. After 1989 the percent of elderly persons 
with a physician visit remained relatively constant. For example, in 1984 75 percent of 
elderly persons in excellent/very good health had a physician visit versus 80 percent in 
1989 and 81 percent in 1991. 



Appendix VI-3 



The visit rate for the elderly for most health status and activity limitation groups also 
significantly increased between 1984 and 1991. For most health status and activity 
Hmitation groups, the increase in the visit rate was gradual in nature. However, for the 
elderly population unable to perform their major activity, between 1989 to 1991 the visit 
rate increased by 7.3 visits per person. This increase in the visit rate among the 
population 65 and over who were unable to perform their major activity may be 
partially related to the growth in the proportion of persons in that activity limitation 
group who were 85 years of age and over. In 1989, 13.5 percent of the elderly who 
were unable to perform their major activity were 85 and over; by 1991 this had 
increased to 16.7 percent (data not shown). Between 1989 and 1991 the visit rate for 
persons 18-64 years of age also increased the most for those unable to perform their 
major activity, though not as much as for the elderly (2.4 additional visits per person). 

Not surprisingly, the presence of at least one chronic condition was associated with 
higher use of physician services. Throughout the period 1984 to 1990, the visit rate for 
elderly persons with a chronic condition fluctuated around 12 visits per person. In 
contrast, between 1990 and 1991, the visit rate increased substantially for elderly 
persons with a chronic condition, from 11.9 visits per person to 14.5. 

Use of physician services and sociodemographic characteristics 

Throughout 1984 to 1990, the mean visit rate for the population 65 years of age and 
over was highest for those with other public program coverage (primarily Medicaid), 
compared to those with Medicare and other coverage (e.g., Medigap pohcies), and 
those with only Medicare (Table VI-3). Among the aged during this time period, those 
with Medicare coverage only were the least likely to have at least one physician visit. 
In 1990 (and each of the study years), for persons 18-64 years of age, use of physician 
services was highest for those with public coverage (11.1 visits per person) and lowest 
for the uninsured (4 visits per person). 

Among the aged with Medicare and other coverage (primarily Medigap), the percent of 
persons with a visit significantly increased between 1984 and 1990. Likewise, among the 
population 18 to 64 years of age with private insurance, the percent of persons with a 
visit also increased. Except for the visit rate for the population 18 to 64 years of age 
with private insurance, no significant time trends in the visit rate were observed for 
either age group. 

Throughout the period 1984-1991, the mean visit rate was similar for the poor/low 
income group (persons with family income at 200 percent or less of the poverty level) 
and the non-poor group for both the aged and the population 18 to 64 years of age; 
the percent of persons with a visit was only slightly higher for the non poor. 



Appendix VI-4 



Regardless of the age group, the percent of persons with a visit significantly increased 
between 1984 and 1990 for both income groups. In general, the mean visit rate also 
increased throughout this time period (the increase was not significant for the non poor 
aged population). 

Data by race were available for 1991 (Table VI-4). When all 5 years are combined, the 
mean visit rate for black persons aged 65 years and over is higher (weighted average of 
10.1 visits per person) than for white persons (weighted average of 8.9 visits per 
person). The percent of elderly persons with a visit, however, is similar (about 84 
percent) by race. For both black persons and white persons, the percent of persons 
with a visit increased between 1984 and 1991, regardless of age. The only significant 
change in the visit rate was the increase between 1984 and 1991 for white persons aged 
65 and over. 

Use of physician services by activity limitation and sociodemographic characteristics 

For persons 65 years of age and over with Medicare and other public coverage, the 
distribution by activity limitation status changed somewhat between 1989 and 1990. In 
1989, 37 percent (data not shown) of those 65 years of age and over with Medicare and 
other public coverage did not have any activity limitation; in 1990, the proportion of the 
Medicare and other public coverage group without an activity limitation increased to 
44.7 percent (Table VI-5). This improvement in the health of the aged population with 
Medicare and other public coverage might reflect the introduction of the Qualified 
Medicare Beneficiary (QMB) program. Under the QMB program, Medicaid pays the 
Medicare cost sharing requirements for qualified persons. Medicare enrollees who 
qualify under the QMB program do so because their income is low (but not low enough 
to receive Supplemental Security Income) and not because of health status. They are 
very likely a healthier population. 

Across all activity limitation groups there were persistent differences in the use of 
physician services by insurance status. For example, regardless of activity limitation 
status, aged persons with Medicare coverage only were the least likely to have had at 
least one physician visit and had the lowest visit rate as compared to Medicare 
enrollees with supplemental insurance (Table VI-6). 

For the aged, the visit rate for the poor/low income group was not significantly different 
in any of the activity limitation categories than the visit rate for the not poor group. 
Among the population 18 to 64 years of age unable to perform their major activity, the 
not poor group had significantly more visits than the poor/low income group. 



Appendix VI-5 



Proportion of physician visits in physicians' offices 

Slightly over half of all physician visits occurred in physicians' offices as opposed to 
other settings (Table VI-7), such as hospital outpatient departments and clinics (8 
percent) and emergency rooms (3 percent). For persons 65 years of age and over, the 
proportion of visits in physicians' offices was highest (60.1 percent) for persons with 
Medicare and other coverage (primarily Medigap coverage). For the population 18 to 
64 years of age, those with private insurance were the most likely to obtain care in 
physicians' offices (60.5 percent of visits). In contrast, the population 18 to 64 years of 
age with public coverage was the least likely to seek care in physicians' offices 
(44.1 percent of visits). 

MULTI\ ARIATE RESULTS 

The findings from the descriptive analysis for health status, income, and insurance were 
supported by the multivariate analysis. 

Probability of having a physician visit 

The odds of having a physician visit are higher for females than males (Table VI-8), 
especially for the 18-64 year old group. In 1990, females 18-64 years of age were 2.37 
times more likely to have a visit than males; females 65 years of age and over were 
1.46 times more likely to have a visit than males. 

In 1986, 1989 and 1990, persons 18-64 years of age residing in non-central city MSA 
areas were slightly more likely than persons residing in non-MSAs to have a physician 
visit. In 1989 and 1990, persons 18-64 years of age in central cities were more likely 
than non-MSA residents to have a visit. In 1984 the likelihood of a person 18-64 years 
of age having a visit was about the same for MSA and non-MSA areas. 

After controlling for other covariates, aged persons residing in MSAs were more likely 
to have a physician visit than persons residing in non-MSA areas in all of the study 
years. For example, in 1990 persons 65 years of age and over residing in non-central 
city MSAs were 1.21 times more likely, and persons residing in central city MSAs were 
1.24 times more likely to have a physician visit than persons residing in non-MSA areas. 

Education appears to have a significant influence on the likelihood of a person 18-64 
years of age having a physician visit, with the odds of having a visit increasing with 
educational level. In each of the study years, for example, persons 18-64 years of age 
without a high school diploma were between 0.81 and .87 times as likely to have a 
physician visit as persons whose highest educational level was a high school diploma. In 



Appendix VI-6 



\ 



contrast, college graduates 18-64 years of age were much more likely to have a 
physician visit than persons whose highest educational level was a high school diploma 
(odds ratio between 1.26 and 1.40). There is no clear pattern for the 65 years of age 
and over group. 

For the 18-64 year old group, persons 45-64 were less likely (odds ratio between 0.81 
and ,89) to have a physician visit than persons 18-44 years of age. This probably 
reflects use by females in their childbearing years. The reverse is true for the over age 
65 group. Among persons 65 years of age and over, those 75 years of age and over 
were more likely (odds ratio between 1.21 and 1.41) to have a physician visit than those 
65-74 years of age. 

Among the elderly, persons with supplemental insurance, regardless of whether it is 
Medicaid (odds ratio of 1.77 in 1990) or private Medigap insurance (odds ratio of 1.91 
in 1990) are more likely to visit a physician than persons with only Medicare coverage. 
Likewise, persons 18-64 years of age vdth insurance, regardless of the source, are much 
more likely to have a physician visit than the uninsured. 

Level of use of physician visits among users 

In each of the study years, females 18-64 years of age had between 23.1 and 26.5 
percent more visits than males (Table VI-9). Among the elderly, females had between 
4.7 percent and 8.9 percent more visits than elderly males. 

Both the descriptive analysis and logistic regression revealed that there is no significant 
difference between black and white persons 65 years of age and over in the likelihood 
of having a visit. Among users there was also no significant difference in the level of 
use between whites and blacks 65 years of age and over. However, among users 18- 
64 years of age, blacks consistently had about 12 percent fewer physician visits than 
whites. 

Among users of physicians, the number of visits per person is higher for persons 
residing in MSA areas compared to persons residing in non-MSA areas. For example, 
persons 18-64 years of age in central cities used between 3 and 7 percent more visits. 
In 1990, persons 65 years of age and over residing in MS As, both central cities and 
non-central cities, used 8 percent more than non-MSA residents. 

In general, the rate of physician visits among persons 18-64 years of age increases as 
educational level increases. This was the same pattern seen for the odds of having a 
visit. Among the elderly, the only significant difference is for persons with at least a 
college education. In 1990, for example, elderly persons with a college degree had 9 



Appendix VI-7 



percent more visits than persons whose highest educational level was a high school 
diploma. 

The same pattern seen by age for the risk of having a physician visit was seen for the 
level of use. Persons 45-64 years of age had fewer visits (about 10 percent in most of 
the study years) than persons 18-44 years of age, and persons 75 years of age and over 
had somewhat more visits (about 5 percent in most of the study years) than persons 65- 
74 years of age. 

Aged persons with insurance supplemental to Medicare have more visits than aged 
persons with only Medicare coverage. The level of use is much higher for persons with 
Medicare and other public coverage. For example, in 1990, persons 65 years of age 
and over with Medicare and other public coverage had 21.7 percent more visits than 
persons with only Medicare coverage, and persons with Medicare and other coverage 
had 8.8 percent more visits. In 1990, among persons 18-64 years of age, persons with 
pubhc coverage had 26.9 percent more visits than the uninsured; persons with private 
coverage had 12.5 percent more visits than the uninsured. 

Trends in use of physician services 

Test for trends in the multivariate analysis were done. Only a few significant trends 
were found. This discussion will only focus on those variables that showed an 
increasing or decreasing trend in use of physician services. For the elderly, the odds of 
persons in poor health having a visit (compared to those in excellent health) declined 
between 1986 (odds ratio of 4.23) and 1990 (odds ratio of 2.72). Most of this decline 
occurred between 1989 and 1990 (see Table VI-8). The odds of elderly persons in non- 
central city MSAs (compared to elderly persons in non-MSAs) having a visit also 
declined from 1.51 in 1984 to 1.21 in 1990. 

For the non-elderly, both persons in fair health and persons in poor health (relative to 
those in excellent health) had a significant decline in the odds of having a visit between 
1986 and 1990. For those in fair health the odds of a visit declined from 2.03 in 1986 
to 1.84 in 1990; for those in poor health the odds of a visit declined from 3.8 to 3.0 
during these same years. 



DISCUSSION 

The NHIS was used to examine patterns of use of physician services for several 
vulnerable groups in the population. For the elderly these include: persons with low 
income; Medicare enroUees without any supplemental health insurance; Medicare 



Appendix VI-8 



enrollees entitled to Medicaid; persons in poor health, or persons with chronic 
conditions or activity limitations; racial minorities; and persons in rural areas. For the 
population 18-64 years of age, an important vulnerable group was the uninsured. 

Use of physician services increased between 1984 and 1991 for both the elderly, 
particularly for those 75 years of age and over, and the non-elderly. It is not clear 
whether this increase reflects improving accessibility to physician services, more concern 
about health problems, or inappropriate utilization. 

Both the descriptive results and the multivariate results confirm that perceived health 
status, activity limitation and presence of a chronic condition are very important 
determinants of use of physician services. Across the baseline period 1986-1990, there 
was a decline in the odds of having a visit for elderly and non-elderly persons in poor 
health. In the post-physician payment reform period, it will be important to monitor 
the trend in use of physician services by persons in the poorest health, particularly if 
poor health is accompanied by low income or inadequate insurance coverage. 

Insurance coverage is also a very important determinant of use of physician services 
since insurance reduces the financial barriers to receiving care. In general, the insured 
use more physician services than the uninsured. Supplemental insurance coverage 
further reduces financial barriers to receiving care. Elderly who lack supplemental 
insurance use fewer physician services than those with the coverage. Additionally, the 
Medicare and other public coverage group contains many medically needy persons who 
are sicker and expected to require more services. These two groups, therefore, may be 
more vulnerable to potential access problems. It will be important to monitor use of 
physician services by persons with only Medicare coverage and persons with Medicare 
and other public coverage in the post-physician payment reform period. 

In summary, the NHIS confirms that prior to physician payment reform, health 
insurance and health status were important determinants of use of physician services. 
Physician payment reform may affect health insurance determinants (by limitations on 
extra billing) as well as income (by affecting patients' out-of-pocket liability for physician 
services). Future analyses using the NHIS should help to identify any impact of 
physician payment reform on access for vulnerable segments of the Medicare 
population, through comparison of use of physician services before and after payment 
reform and through comparisons with the under 65 population. 



Appendix VI-9 



Endnotes 

Definitions of sociodemographic characteristics, health status categories, and geographic 
areas: 

SOCIODEMOGRAPHIC CHARACTERISTICS 

Insurance coverage: 

For the population 65 years of age and over, this appendix categorizes insurance status 
as Medicare only, Medicare and other public health coverage, Medicare and other 
insurance, insurance other than Medicare, and unknown or none. Each of these groups 
is mutually exclusive. The Medicare and other public coverage group primarily includes 
persons with Medicare and Medicaid. The Medicare and other group primarily includes 
Medicare enrollees with privately purchased "Medigap" coverage and Medicare 
enrollees with employer-sponsored supplementary coverage. 

For the population 18-64 years of age insurance status was defined as pubhc coverage, 
insured but not through a public program, uninsured, and unknown. As for the over 65 
population, these categories are also mutually exclusive. Public coverage includes 
Medicare, Medicaid, and any public assistance programs that pay for health care. For 
both age groups, Medicaid coverage was imputed for persons with Aid to Families with 
Dependent Children or Supplemental Security Income who did not report Medicaid 
coverage. The insurance other than Medicare and the unknown/no coverage groups for 
the population 65 years of age and over, and the unknown insurance status group for 
persons 18-64 years of age are included in the totals but are not shown separately in 
this analysis. 

Income: 

The NHIS collects information on family income, but in 1989 family income was not 
reported by 16 percent of all respondents and by about 23 percent of the elderly. 
Therefore, income was imputed for persons with an unknown value using a model that 
included family size, race, whether there is a married couple in the family, the number 
of adults in the family in the labor force, and other variables. 

Race: 

Race is shown as only white or black in the tables; however, the totals include persons 
of other race. 



Appendix VI-10 



HEALTH STATUS 

Self-reported health status: 

There are five levels of self-reported health status in the NHIS: excellent, very good, 
good, fair, and poor. For the purposes of this analysis, persons who reported excellent 
and very good health were combined into one group, and persons who reported fair 
and poor health were combined into another group. 

Activity limitation status: 

There are four levels of activity limitation in the NHIS: unable to perform major 
activity, limited in kind or amount of major activity, limited in other activities, and not 
limited. The not limited category includes persons with an unknown activity limitation 
level. For the purpose of this analysis, data for persons with a limitation in kind or 
amount of major activity or a limitation in other activities have been combined into a 
category called "hmited." A major activity is defined in the NHIS as working or 
keeping house for persons 18-69 years of age, and capacity for independent living for 
persons 70 years of age and over. 

Chronic and acute conditions: 

Chronic conditions are defined by NCHS as conditions with an onset of more than 
3 months prior to the interview and a duration of more than 3 months. Certain 
conditions, such as emphysema, are always considered chronic. 

NCHS defines an acute condition as any disease or injury with an onset in the 3-month 
period prior to the interview. To be included in the survey, the acute condition must 
have had an impact on behavior, such as causing the person to cut down on his or her 
usual activity, or must have resulted in contact with a physician. 

GEOGRAPHIC AREA 

Geographic area was defined in terms of census region: northeast, midwest, south, and 
west. It was also defined in terms of whether or not the person resided in an MSA. 
MSAs are further divided into central city and non-central city areas. 



Appendix VI- 11 



REFERENCES 

Dor, A., Holahan, J. (1990). Urban-rural differences in Medicare physician expenditures. 
Inquiry, 27 (winter): 307-18. 

Health Care Financing Administration, Second Annual Report to Congress "Utilization 
and Access to Care" May 1992. 

Spillman B.C. The impact of being uninsured on utilization of basic health care services. 
Inquiry , 29 (winter): 457-66. 



Appendix VI- 12 



Table Vl-i. 

Pocent of penou with at leait one pfayiidait viiit and 
1990, and 1991. 



Age 



nnmber of vistta per peraon. by age: 1984, 1986, 1989 

Percent chflnge 1984-91 



Percent 

distribittioa 

of persons (1) 



1991 



Percent with a visit 



Mean number of 
visits po' person 



Mean 
Percent number of 
with a visits 

visit per person 



1984 1986 1989 1990 1991 



1984 1986 1989 1990 1991 



65 years and 
over 



100.0 



82 83 83 86 86 



8.2 9.1 8.9 9.2 10.4 



4.8 



26.7 



65-74 years 60.4 81 81 84 84 85 

75 and over 39.6 84 85 88 88 88 



7.7 8.1 8.2 8.5 9.2 4.5 19.3 

9.1 10.6 9.9 10.1 12.3 5.3 35.5 



18-64 years 



100.0 



70 71 72 73 



73 



4.9 5.2 5.2 5.4 5.4 



3.9 



9.2 



(1) Distribution for the 65 and over population based on 30.3 million persons; distributi<» for the 18-64 year old population 
based on 152.9 million persons. 



Source: National Health Interview Survey, National Center for Health Statistics. 



Table VI-2. Percent of persons with at least one physician visit and mean number of visits per person, 
by selected health status measures, and age: 1984, 1986, 1989, 1990, and 1991. 



Percent 

distribution 

of persons (2) 

1991 



Percent with a 
physician visit 



1984 1986 1989 1990 1991 



Mean number of 
visits per person 



1984 1986 1989 1990 1991 



Health status and age 
Self-reported health status 



65 years and over (1) 


100.0 


82 


83 


85 


86 


86 


8.2 


9.1 


8.9 


9.2 


10.4 


Excellent/Very Good 

Good 

Fair /Poor 


38.3 
32.3 
28.9 


75 
82 
90 


75 
84 
91 


80 
86 
92 


80 
87 
92 


81 
87 
92 


5.4 

6.8 

12.9 


5.6 

7.6 

14.8 


5.5 

7.7 

14.7 


5.5 

8.4 

15.4 


6.1 

8.9 

17.9 




18-64 years (1) 


100.0 


70 


71 


72 


73 


73 


4.9 


5.2 


5.2 


5.4 


5.4 


Excellent/Very Good 

Good 

Fair/Poor 


67.0 

23.4 

9.3 


67 
73 
85 


68 

74 
85 


70 
75 
87 


70 
76 
87 


70 
76 
87 


3.4 

5.6 

12.5 


3.7 

5.6 

14.8 


3.7 

6.0 

14.4 


3.6 

6.7 

15.3 


3.7 

6.3 

15.1 


Activity limitation 


65 years and over 


100.0 


82 


83 


85 


86 


86 


8.2 


9.1 


8.9 


9.2 


10.4 


Not limited 

Limited 

Unable to perform major activity 


62.1 
27.3 
10.6 


77 
89 
93 


77 
91 
92 


81 
92 
95 


81 
92 
94 


82 
92 
94 


5.5 
10.3 
18.3 


6.0 
11.0 
21.6 


5.9 
11.6 
19.5 


5.9 
11.7 
22.3 


6.5 
13.0 
26.8 




18-64 years 


100.0 


70 


71 


72 


73 


73 


4.9 


5.2 


5.2 


5.4 


5.4 


Not limited 

Limited 

Unable to perform major activity 


86.8 
8.6 

4.6 


68 
85 
90 


69 
86 
90 


70 
86 
91 


70 
88 

92 


71 
88 
91 


3.8 

9.8 

17.3 


4.0 
10.1 
20.3 


4.0 

9.9 

20.0 


4.0 
10.9 
21.5 


3.9 
11.1 
22.4 


Presence of at least one 
chronic conditon 


65 years and over 


100.0 


82 


83 


85 


86 


86 


8.2 


9.1 


8.9 


9.2 


10.4 


Yes 

No 


66.4 
33.6 


89 
68 


89 
69 


91 

74 


91 

72 


92 
75 


11.5 
1.7 


12.6 
2.0 


12.3 
2.3 


11.9 
2.3 


14.5 
2.4 




18-64 years 


100.0 


70 


71 


72 


73 


73 


4.9 


5.2 


5.2 


5.4 


5.4 


Yes 
No 


35.1 
64.9 


84 
63 


84 
64 


85 
65 


85 
66 


86 
66 


10.1 
2.2 


10.7 
2.2 


10.9 
2.2 


10.6 
2.2 


11.3 
2.1 



(1) Total includes persons with unknown health status. 

(2) Distribution for the 65 and over population based on 30.3 million persons; distribution for the 18-64 year old population 

based on 152.9 mUlion persons. 



Source: National Health Interview Survey, National Center for Health Statistics. 



Table VI-3. Percent of persons with a physician visit and mean number of visits per person, by selected 
sociodemographic characteristics: 1984, 1986, 1989, and 1990. 



Percent 
distribution of 
persons 



Percent with a 
physician visit 



Mean number of 
visits per person 



1990 



1984 1986 1989 1990 



1984 1986 1989 1990 



Socio-demographic characteristics 



Health Insurance status 



65 years and over (1) 


100.0 


82 


83 


85 


86 


8.2 


9.1 


8.9 


9.2 


Medicare only 


14.9 


76 


73 


79 


78 


7.6 


8.3 


7.5 


8.1 


Medicare and other public 




















program 


7.8 


89 


86 


90 


88 


11.9 


14.0 


13.1 


14.1 


Medicare and other 




















coverage 


73.9 


84 


85 


87 


87 


8.3 


8.9 


8.8 


8.9 



18-64 years (2) 


100.0 


70 


71 


72 


73 


4.9 


5.2 


5.2 


5.4 


Public program 


6.2 


84 


83 


85 


85 


10.1 


11.9 


11.1 


11.1 


Insured but not 




















public program 


76.7 


72 


73 


75 


75 


4.7 


5.0 


5.1 


5.2 


Uninsured 


17.1 


57 


57 


57 


60 


3.7 


3.6 


3.2 


4.0 



Income Level 



65 years and over 


100.0 


82 


83 


85 


86 


8.2 


9.1 


8.9 


9.2 


Poor/Lx)w income 
Not poor 


42.6 
57.4 


81 
82 


81 

84 


84 
86 


84 
87 


8.4 
8.1 


9.3 
8.9 


9.1 
8.7 


9.7 
8.8 



18-64 years 


100.0 


70 


71 


72 


73 


4.9 


5.2 


5.2 


5.4 


Poor/Low income 
Not poor 


27.3 
72.7 


67 
72 


68 

72 


69 

73 


70 
74 


5.1 
4.8 


5.7 
5.0 


5.4 
5.1 


5.9 

5.2 



(1) Includes persons with insurance other than Medicare and unknown insurance. 

(2) Includes persons with imknown insurance. 



Source: National Health Interview Survey, National Center for Health Statistics. 



Table VI-4. Percent of persons with at least one physician visit and mean number of visits per person, 
by race: 1984, 1986, 1989, 1990 and 1991. 



Percent 

distribution 

of persons (2) 



Percent with a 
physician visit 



Mean number of 
visits per person 



1991 



1984 1986 1989 1990 1991 



1984 1986 1989 1990 1991 



65 years and over (1) 




100.0 


82 


83 


85 


86 


86 


8.2 


9.1 


8.9 


9.2 


10.4 


White 




89.8 


82 


83 


85 


86 


86 


8.2 


9.1 


8.7 


9.1 


10.5 


65-74 years of age 




53.9 


81 


81 


84 


85 


85 


7.6 


8.1 


8.0 


8.5 


9.4 


75 years of age and over 




35.9 


84 


86 


88 


88 


88 


9.0 


10.8 


9.7 


10.1 


12.1 


Black 




8.5 


82 


81 


85 


84 


86 


9.8 


9.1 


11.0 


9.7 


10.4 


65-74 years of age 




5.3 


81 


81 


84 


82 


83 


8.8 


8.9 


10.0 


9.2 


7.3 


75 years of age and over 


(3) 


3.1 


82 


83 


86 


87 


91 


11.4 


9.2 


12.7 


10.4 


15.7 



18-64 years (1) 



100.0 



70 



71 



72 73 



73 



4.9 



5.2 5.2 



5.4 5.4 



White 
Black 



84.0 
11.8 



71 
70 



72 
69 



73 
72 



73 
72 



74 
73 



5.0 
4.8 



5.3 
5.2 



5.3 
4.7 



5.4 
5.2 



5.5 
5.1 



(1) Total includes persons with race listed as "other". 

(2) Distribution for the 65 and over population based on 30.3 million persons; distribution for the 18-64 year old population 

based on 152.9 million persons. 

(3) Relative standard errors for mean number of visits in 1984 and 1986 >15% but <20%. 



Source: National Health Interview Survey, National Center for Health Statistics. 



I 



Table VI-5. Distribution of persons by selected sociodemographic characteristics and activity 
limitation status: 1990 

Percent Distribution 



Sociodemographic 
characteristics 

Health insurance status 



Number of 
persons 
(in millions) 



Total 



Unable to 

to perform 

major 

activity 



Limited 



(1) Includes persons with insurance other than Medicare and unknown insurance. 

(2) Includes persons with unknown insurance. 



Not 
limited 



65 years and over (1) 


29.8 


100.0 


10.2 


27.3 


62.5 


Medicare only 


4.4 


100.0 


13.9 


27.3 


58.8 


Medicare and other public 












program 


2.3 


100.0 


21.2 


34.2 


44.7 


Medicare and other 












coverage 


22.0 


100.0 


8.2 


26.9 


64.9 



18-64 years (2) 


151.7 


100.0 


4.5 


8.3 


87.2 


Public program 


9.3 


100.0 


33.1 


16.3 


50.6 


Insured but not 












public program 


116.4 


100.0 


2.2 


7.7 


90.1 


Uninsured 


26.0 


100.0 


4.3 


8.3 


87.4 



Income level 












65 years and over 


29.8 


100.0 


10.2 


27.3 


62.5 


Poor/Low income 
Not poor 


12.7 
17.1 


100.0 
100.0 


12.9 
8.2 


32.0 
23.7 


55.0 
68.0 



18-64 years 


151.7 


100.0 


4.5 


8.3 


87.2 


Poor/Low income 
Not poor 


41.4 
110.3 


100.0 
100.0 


9.6 
2.5 


10.5 

7.5 


80.0 
89.9 



Source: National Health Interview Survey, National Center for Health Statistics. 



Table VI-6. Percent of persons with a physician visit and mean number of visits per person, by selected 
sociodemographic characteristics and activity limitation: weighted average of 1984, 1986, 
1989, and 1990 



Unable to perform major 
activity 



Limited 



Not Limited 



Percent Mean 

with a number 

physician of 

visit visits 



Percent Mean 

with a number 

physician of 

visit visits 



Percent Mean 

with a number 

physician of 

visit visits 



Socio-demographic characteristics 



Health insiirance status 



65 years and over (1) 


94 


20.1 


92 


11.1 


79 


5.8 


Medicare only 


91 


18.0 


86 


9.1 


70 


4.7 


Medicare and other public 














program 


95 


23.7 


91 


12.6 


83 


7.4 


Medicare and other 














coverage 


95 


20.5 


93 


11.4 


82 


6.0 



18-64 years (2) 


91 


19.4 


86 


10.2 


69 


3.9 


Public program 


92 


18.1 


90 


12.5 


78 


6.1 


Insured but not 














public program 


93 


22.9 


88 


10.3 


72 


4.1 


Uninsured 


85 


14.9 


77 


7.7 


54 


2.5 



Income level 



65 years and over 


94 


20.1 


92 


11.1 


79 


5.8 


Poor/Low income 
Not poor 


93 
95 


19.4 
20.9 


90 
94 


10.8 
11.3 


77 
81 


5.5 
5.9 




18-64 years 


91 


19.4 


86 


10.2 


69 


3.9 


Poor/Low income 
Not poor 


90 
93 


17.2 
22.4 


83 
88 


9.6 
10.5 


64 
71 


3.6 
4.0 



(1) Includes persons with insurance other than Medicare and unknown insurance. 

(2) Includes persons with imknown insurance. 



Source: National Health Interview Survey, National Center for Health Statistics. 



Table VI-7. Proportion of physician visits in physicians' offices by insurance category: 1984-1990. 

Year Average (3) 

1984 1986 1989 1990 1984-1990 

Insurance category and age 



Total 


56.6 


54.7 


58.2 


58.9 


57.4 




65 years and over (1) 


57.2 


53.7 


59.2 


58.5 


57.8 


Medicare only 

Medicare & other public program 

Medicare & other coverage 


52.7 
46.3 
59.9 


39.5 
39.9 
59.3 


55.8 
58.2 
61.1 


57.0 
51.0 
59.8 


51.5 
50.6 
60.1 




18-64 years (2) 


56.5 


55.0 


57.8 


59.1 


57.2 


Public program 

Insured but not public program 

Uninsured 


43.5 
59.6 
50.4 


41.5 
58.4 
48.6 


45.3 
61.4 
50.8 


45.8 
62.3 
53.5 


44.1 
60.5 
50.8 



(1) Includes persons with insurance other than Medicare and unknown insurance. 

(2) Includes persons with unknown insurance. 

(3) Weighted proportional to the inverse variance. 



Source: National Health Interview Survey, National Center for Health Statistics. 



Table VI-8. Risk (odds ratios) of having a physician visit for selected variables by age: 1984, 1986, 1989, 
and 1990. 



1984 



1986 



1989 



1990 





18-64 yrs 


65 + yrs 


18-64 yrs 


65 -1- yrs 


18-64 yrs 


65 + yrs 


18-64 yrs 


65 -1- yrs 


Independent Variables 


of age 


of age 


of age 


of age 


of age 


of age 


of age 


of age 


Intercept 


0.52 • 


0.51 • 


0.48 • 


0.36 ♦ 


0.47 • 


0.69 ♦ 


0.51 • 


0.54 . 


Income to poverty ratio 


1.08 . 


1.07 • 


1.08 • 


1.14 • 


1.06 • 


1.09 ♦ 


1.05 ' 


1.11 • 


Sex (0=male, 1= female) 


2.10 • 


1.36 • 


2.18 • 


1.45 ♦ 


2.24 » 


1.31 • 


2.37 " 


1.46 • 


Race (a) 


















Black 


1.04 


1.09 


0.92 • 


1.15 


1.02 


1.18 


1.04 


1.10 


Other 


0.72 » 


1.37 


0.69 • 


0.64 


0.70 . 


0.76 


0.73 • 


0.80 


Self-reported health status (b) 


















Very good 


1.38 • 


1.51 • 


1.31 • 


1.55 • 


1.31 • 


1.61 • 


1.32 • 


1.57 • 


Good 


1.41 • 


1.80 • 


1.50 • 


2.14 . 


1.36 • 


1.80 • 


1.39 • 


1.83 . 


Fair 


2.01 • 


2.34 . 


2.03 • 


2.71 . 


1.95 . 


2.13 • 


1.84 . 


2.54 . 


Poor 


3.15 • 


3.37 • 


3.80 • 


4.23 • 


3.70 • 


3.64 • 


3.01 « 


2.72 • 


Activity limitation (c) 


















Unable to perform major activity 


1.75 . 


1.52 • 


1.63 • 


1.30 


1.85 • 


1.75 • 


2.34 • 


1.69 • 


Limited in kind/amount of 


















major activity 


1.26 . 


1.03 


1.27 . 


1.46 • 


1.28 ' 


1.17 


1.42 • 


1.37 • 


Limited in other activity 


1.01 


1.06 


1.11 


1.11 


1.19 • 


1.30 • 


1.36 * 


1.35 • 


Presence of chronic condition 


















(no=0; yes=l) 


2.35 • 


2.74 • 


2.31 • 


2.77 • 


2.33 • 


2.58 • 


2.19 • 


2.59 • 


Geographic area of residence (d) 


















MSA - central city 


1.00 


1.21 • 


1.06 


1.23 • 


1.13 • 


1.12 


1.08 • 


1.24 • 


MSA - not central city 


1.01 


1.51 • 


1.09 • 


1.36 • 


1.07 * 


1.27 * 


1.10 • 


1.21 • 


Highest educational level (e) 


















0-11 years 


0.81 • 


0.95 


0.86 • 


0.86 


0.87 * 


0.87 • 


0.87 • 


0.90 


1-3 years college 


1.14 • 


1.35 • 


1.22 » 


1.15 


1.21 • 


1.11 


1.19 • 


1.04 


College graduate or more 


1.26 . 


1.27 ♦ 


1.28 • 


1.03 


1.28 ♦ 


1.28 • 


1.40 • 


1.15 


Age division (f) 


0.81 • 


1.23 • 


0.86 • 


1.41 • 


0.87 » 


1.29 • 


0.89 » 


1.21 * 


Insurance (g) 


















Medicare and other public 


















coverage 


NA 


1.89 • 


NA 


1.67 • 


NA 


1.74 • 


NA 


1.77 ♦ 


Medicare and other coverage 


NA 


1.67 • 


NA 


2.13 • 


NA 


1.79 • 


NA 


1.91 • 


Other than Medicare 


NA 


0.98 


NA 


1.31 


NA 


1.16 


NA 


1.24 


Public coverage 


2.37 • 


NA 


2.24 . 


NA 


2.36 • 


NA 


1.99 • 


NA 


Private coverage 


1.74 . 


NA 


1.75 • 


NA 


2.05 • 


NA 


1.81 • 


NA 



(a) Reference group: White 

(b) Reference group: Excellent health status 

(c) Reference group: Not limited 

(d) Reference group: Non-MSA area 

(e) Reference group: High school diploma 

(f) Age division for 18-64 year olds: 18-44 = 0, 45-64=1. Age division 65 and over group: 65-70 = 0, 75 and over=l 

(g) Reference group: Medicare only for over 65 mode. Uninsured for 18-64 year old model 



* Coefficient corresponding to odds ratio significant at p< = .05. 



Table VI-9. Coefficients for use of physician visits among users for selected variables by age: 1984, 1986, 1989, 
and 1990. 



1984 



1986 



1989 



1990 





18-64 yrs 


65 + yrs 


18-64 yrs 


65 -1- yrs 


18-64 yrs 


65 -f yrs 


18-64 yrs 


65 -1- yrs 




of age 


of age 


of age 


of age 


of age 


of age 


of age 


of age 


Independent Variables 


















Intercept 


0.339 * 


0.386 * 


0.334 * 


0.436 * 


0.298 * 


0.545 * 


0.311 * 


0.421 * 


Income to poverty ratio 


0.009 * 


0.023 * 


0.006 


0.017 * 


0.006 * 


0.008 


0.002 


0.013 * 


Sex (0 = male, 1= female) 


0.231 * 


0.063 * 


0.244 * 


0.063 * 


0.241 * 


0.047 * 


0.265 * 


0.089 * 


Race (a) 


















Black 


-0.113 * 


0.063 


-0.123 * 


-0.010 


-0.123 ' 


-0.003 


-0.119 * 


0.023 


Other 


-0.085 * 


-0.038 


-0.105 * 


-0.008 


-0.038 


-0.036 


-0.111 * 


0.098 


Self-reported health status (b) 


















Very good 


0.144 * 


0.130 * 


0.142 * 


0.186 * 


0.158 * 


0.131 * 


0.144 * 


0.133 * 


Good 


0.295 * 


0.252 * 


0.280 * 


0.339 * 


0.303 • 


0.279 * 


0.311 * 


0.287 * 


Fair 


0.542 * 


0.477 » 


0.560 ♦ 


0.520 * 


0.552 * 


0.505 * 


0.590 * 


0.491 * 


Poor 


0.887 * 


0.823 * 


0.860 * 


0.884 * 


0.876 * 


0.863 * 


0.928 » 


0.868 * 


Activity limitation (c) 


















Unable to perform major activity 


0.459 * 


0.279 * 


0.462 * 


0.338 * 


0.489 * 


0.255 * 


0.501 • 


0.347 * 


Limited in kind/amouiit of 


















major activity 


0.270 * 


0.148 * 


0.244 * 


0.210 * 


0.301 * 


0.230 * 


0.341 * 


0.291 * 


Limited in other activity 


0.112 * 


0.122 * 


0.162 * 


0.149 * 


0.164 * 


0.169 * 


0.250 * 


0.191 * 


Presence of chronic condition 


















(no=0; yes=l) 


0.365 * 


0.389 * 


0.369 • 


0.398 * 


0.359 • 


0.340 * 


0.350 * 


0.291 « 


Geographic area of residence (d) 


















MSA - central city 


0.068 * 


0.131 * 


0.067 » 


0.063 * 


0.051 * 


0.043 * 


0.034 * 


0.082 * 


MSA - not central city 


0.041 * 


0.075 * 


0.065 * 


0.076 * 


0.034 * 


0.057 * 


0.042 * 


0.085 * 


Highest educational level (e) 


















0-1 1 years 


-0.038 * 


0.005 


-0.066 * 


-0.041 


-0.007 


-0.020 


-0.041 * 


0.013 


1-3 years college 


0.050 * 


0.035 


0.028 * 


-0.022 


0.053 * 


-0.036 


0.073 * 


0.350 


College graduate or more 


0.062 * 


0.092 * 


0.089 * 


0.040 


0.072 * 


0.066 * 


0.077 * 


0.090 * 


Age division (f) 


-0.107 * 


0.055 * 


-0.087 * 


0.052 * 


-0.106 * 


0.050 * 


-0.101 * 


0.044 * 


Insurance (g) 


















Medicare and other public 


















coverage 


NA 


0.230 * 


NA 


0.148 * 


NA 


0.218 * 


NA 


0.217 * 


Medicare and other coverage 


NA 


0.055 * 


NA 


0.042 


NA 


0.056 * 


NA 


0.088 * 


Other than Medicare 


NA 


-0.033 


NA 


0.071 


NA 


0.056 


NA 


-0.012 


Public coverage 


0.259 * 


NA 


0.304 * 


NA 


0.334 * 


NA 


0.269 * 


NA 


Private coverage 


0.082 * 


NA 


0.098 * 


NA 


0.144 * 


NA 


0.125 * 


NA 


R-square 


0.19 


0.19 


0.19 


0.20 


0.20 


0.20 


0.20 


0.19 



(a) Reference group: White 

(b) Reference group: Excellent health status 

(c) Reference group: Not limited 

(d) Reference group: Non-MSA area 

(e) Reference group: High school diploma 

(f) Age division for 18-64 year olds: 18-44 = 0, 45-64= 1 
Age division 65 and over group: 65-74 = 0, 75 and over=l 

(g) Reference group: Medicare only for over 65 model 

Uninsured for 18-64 year old model 



* Coefficient significant at p< = .05. 



t 



Appendix VII 
Trends in Physician Supply 



Prepared by: Lawrence E. Kucken 

Office of Research and Demonstrations 

Health Care Financing Administration 

April 1994 

Revised May 31, 1994 



Appendix VII 

Trends in Physician Supply 

INTRODUCTION 

This appendix uses physician supply data as an indicator of potential access to services 
under physician payment reform. It describes patterns of physician supply up through 
the implementation of the MFS in 1992. These data serve to update the basehne trend 
data presented in the 1993 access report to Congress. 

Measuring physician supply patterns is clearly an important aspect of monitoring access 
under physician payment reform. However, possible impacts of physician pajmient 
reform on physician supply are likely to occur as long-term changes when compared 
with its effects on service delivery patterns. The data presented in this appendix should 
be viewed only as a first step toward monitoring physician supply response. 

Long-term influences of the financial incentives contained in the MFS may be seen in 
relative numbers and geographic distribution of primary care and medical speciahsts, 
and surgical specialists^ As noted in the 1993 access report to Congress, the MFS is 
structured to increase medical service payments relative to surgical service payments. 
Similarly, the MFS's geographic adjustment factor increases payments to physicians 
practicing in rural or low cost geographic areas relative to higher cost urban areas. 
Because the fee schedule itself only addresses unit price, the MVPS was estabhshed to 
help control the rate of growth in total physician expenditures. Under the MVPS, 
annual fiscal year target standards are established for surgical and nonsurgical (medical) 
physician services [Federal Register, November 25, 1991, Vol. 56(227)]. In fiscal years 
1991, 1992, and 1993, targets for surgical services were set at 3.3 percent, 6.5 percent, 
and 8.4 percent, respectively; targets for nonsurgical (medical) services were set at 
8.6 percent, 11.2 percent, and 10.8 percent, respectively. The difference in the surgical 
and nonsurgical targets mostly reflects the differential impact of legislative changes on 
expenditures for these services. The surgical target for 1994 was estabhshed at 
8.6 percent. For 1994, a new target was established for primary care services and set at 
10.5 percent; the target for other nonsurgical services was set at 9.2 percent 
[Federal Register, December 2, 1993, Vol. 58 (230)]. 

Monitoring long-term supply trends for these physician groups can reveal payment 
effects on physician supply patterns. Similarly, the urban/rural incentives contained 
within the MFS suggest the importance of monitoring geographic patterns along these 
lines. 



^ For ease of reference, the physician group "primary care and medical specialists" will be referred to 
as "medical specialists." "Surgical specialists" are also referred to as "surgeons." 

Appendix VII- 1 



METHODS 

Data 

Two data sources are used for information presented in this appendix. They are: the 
Health Resources and Services Administration's Area Resource File (ARF) and 
HCFA's Denominator File. These source data were used by HCFA and Project HOPE 
to construct an analysis file containing physician-to-population ratios for the period 1984 
through 1992 by physician specialty type (medical/surgical) and geographic areas. 

Measures 

Physician-to-population ratios were developed using counts of doctors of medicine 
(MDs),^ as recorded on the ARF as the numerators; the denominators were generated 
from HCFA's Denominator File. The numerators represent estimates as of January 1 
of each respective year. In all, 29 physician specialties were included as the basis for 
the ratio calculations presented in this appendix and are listed in Table VII- 1 according 
to primary care and medical, and surgical specialist categories. Surgical specialties were 
based on the surgical services appearing in the November 25, 1991 Federal Register . 
The primary care and medical specialties represent the residual categories appearing in 
the ARF, but exclude those in which physicians are unlikely to render care to Medicare 
beneficiaries.^ 

The denominators were based upon counts of total Medicare beneficiaries ehgible for 
(Part B) physician services, including the aged, disabled, and end stage renal disease 
(ESRD) categories." Partial-year ehgibility was taken into account by computing person- 
months of eligibihty, and then annualizing the data. 



^ Doctors of osteopathy were not included because of a lack of consistent data on these providers. 
Additionally, Federal physicians, such as those serving in the National Health Service Corps (NHSC) 
were not included because of data limitations. These exclusions may result in understating physician 
availability, particularly in rural areas served by NHSC physicians. Similarly, physician availability may 
be understated for areas with relatively large proportions of doctors of osteopathy. Conversely, 
physicians employed by HMOs could not be excluded because county-level data were lacking. Similarly, 
it was not possible to exclude physicians who do not accept Medicare patients. These factors would tend 
to overstate physician availability for Medicare patients affected by the fee schedule. 

^ The following specialties were excluded from the ratio calculation: pediatrics, pediatric allergy, 
pediatric cardiology, aerospace medicine, child psychiatry, forensic pathology, general preventive 
medicine, public health, other specialties (not listed), and unspecified specialty. 

" Medicare HMO enroUees were included in the counts of beneficiaries because it was not possible 
to exclude HMO physicians in the construction of the numerator. 

Appendix VII-2 



Three geographic groupings are used in this analysis including: the four U.S. census 
regions, the ten metropolitan/nonmetropolitan areas described in Appendix II, Technical 
Note C, and the four Ex Ante impact areas.' 

RESULTS 

Table VII-2 shows the number of total physicians, medical specialists, surgical 
speciahsts, and the ratios of medical-to-surgical specialists for the period 1984-92. In 
1984, there were 2.04 medical speciahsts for every surgeon practicing in the 
United States. This ratio increased slowly but steadily throughout the period reaching 
2.27 in 1992, indicating a growth in the concentration of medical speciahsts relative to 
surgeons until the time of MFS implementation. 

Tables VII-3 through VII-5 present physician-to-population ratios for the 1984-92 study 
period. Average annual rates of change are shown as summary trend data for the years 
1984 through 1991 and for the most recent 1991-92 period. Data are presented by 
census regions, metropohtan/nonmetropohtan groups, and Ex Ante impact areas. 

Table VII-3 shows these trend data based on total numbers of medical and surgical 
speciahsts. These ratios indicate a steady year-to-year upward trend in the total 
physician-to-population ratios from 1,249 in 1984 to 1,352 physicians per 100,000 
beneficiaries in 1991 for an average annual increase of 1.14 percent. From 1991 to 
1992 this ratio increased by 1.33 percent suggesting only a modest acceleration of 
physician supply growth in the year immediately prior to the MFS implementation. 

Throughout the period 1984-91, the number of physicians per 100,000 beneficiaries in 
the Northeast and West census regions were much higher than the rest of the Nation. 
At the beginning of 1992, physician-to-population ratios in the Northeast and West 
(1,628 and 1,589) were about 33 percent greater, on average, than the corresponding 
ratios in the Midwest and South (1,189 and 1,222). Average annual rates of growth 
from 1984 through 1991 were the highest in the Northeast (1.88 percent) increasing 
somewhat from 1991 to 1992 (2.07 percent). Figure VII-1 illustrates these regional 
differences and the general upward trends in the physician-to-population ratios during 
the 8 years comprising the period. 

With respect to urban/rural geographic patterns, metropolitan areas had about three 
times the number of physicians per 100,000 beneficiaries than did the nonmetropolitan 



^ Ex Ante impact areas were defined in terms of State groupings based on the estimated impact of 
overall physician payment reform as published in the November 25, 1991, Federal Register Vol. 56(227). 
States were grouped according to the overall estimated change in Medicare physician payments by the 
year 1996, as follows: 1) "increase" (+4 percent to +12 percent); "no change" (+3 percent to -3 
percent); "moderate decrease" (-4 percent to -9 percent); and 4) "large decrease" (-10 percent to -20 
percent). 

Appendix VII-3 



areas for each of the years shown. For example, in 1992, there were 1,672 physicians 
per 100,000 beneficiaries in metropolitan areas compared to 556 in nonmetropolitan 
areas. At the extremes, the large core metropohtan areas had a ratio of 2,119 
physicians per 100,000 in 1992, over eight times the concentration of physicians in thinly 
populated (adjacent and nonadjacent), nonmetropolitan areas (254 and 258, 
respectively). 

Metropolitan areas had an average annual growth of 1.19 percent from 1984 through 
1991. From 1991 to 1992 the increase was 1.58 percent. Large metropolitan core 
areas which had been increasing by an average annual rate of 1.51 percent during the 
1984-1991 period grew by an even faster rate of 2.22 percent from 1991 to 1992. 
Overall, the nonmetropolitan areas had a lower growth rate during the 1984-91 period 
(.39 percent), and a decrease of -.71 percent from 1991-92. The most rural (thinly 
populated, nonadjacent) areas experienced the greatest decline in physician supply 
dropping by -2.27 percent from 1991 to 1992. Yearly declines in the physician-to- 
population ratio have been occurring in all nonmetropolitan areas since 1989. 

The Ex Ante group comprised of the "no change" in payment areas experienced the 
greatest annual increase in physicians per 100,000 beneficiaries from 1984 to 1991 (1.55 
percent) with a**similar increase (1.48 percent) occurring from 1991 to 1992. Those 
groups comprised of "moderate decrease" in payment areas had a higher rate of change 
from 1991 to 1992 (1.79 percent) contrasted with 1.29 average annual increase during 
the prior years. 

Table VII-4 shows surgical speciahsts per 100,000 Medicare beneficiaries. As shown, 
the average annual change in surgeon-to-population ratios was nominal from 1984 
though 1991 increasing from 411 to 418 surgeons per 100,000 beneficiaries for an 
average annual increase of less than one-quarter of a percent. The largest increases 
occurred during the middle of the period when this ratio increased from 409 surgeons 
in 1987 to 418 surgeons per 100,000 beneficiaries in 1989 for an annual growth rate of 
1.0 percent for that period. 

The relative concentrations of surgeons in the Northeast and West exceeded the rest of 
the country throughout the entire study period by 22 to 27 percent. Although the rates 
of change in surgeons per 100,000 were nominal in all of the census regions, the 
Northeast showed the greatest increases of .78 percent during the 1984-91 period and 
.64 percent from 1991 to 1992. 

Substantial geographic differences are apparent between the metropolitan and 
nonmetropolitan areas for surgeons; the metropolitan areas had about three times as 
many surgeons per 100,000 beneficiaries during the 1984-91 period. The 1991 ratio for 
metropolitan area surgeons was 513 per 100,000 beneficiaries compared to 159 per 
100,000 beneficiaries for nonmetropohtan areas. These ratios remained relatively 
constant during the 1991-92 period. Concentrations of surgeons were very high in the 

Appendix VII-4 



large core metropolitan areas in 1992 (651 per 100,000 beneficiaries). In contrast, 
nonmetropolitan thinly populated adjacent and nonadjacent areas showed ratios of 
30 and 40 surgeons per 100,000 beneficiaries. 

Table VII-5 contains medical specialists per 100,000 Medicare beneficiaries for the 
1984-92 study period. During the years 1984-91 medical specialist-to-population ratios 
grew at a relatively high average annual growth rate of 1.55 percent. From 1991 to 
1992 this ratio increased by 1.71 percent. In 1992, the ratio for the United States was 
950 per 100,000 beneficiaries. 

Medical specialist ratios among census regions reveal even a higher concentration in the 
Northeast and West relative to the Midwest and South as compared to the supply of 
surgeons. On average, the combined Northeast and West census regions exceeded the 
rest of the country in medical speciahsts per 100,000 beneficiaries during the 1984-91 
period from 34 to 36 percent. No changes in this distribution pattern occurred between 
1991 and 1992. 

The highest average annual rate of change during the 1984-91 period occurred in the 
Northeast (2.38 percent). During the 1991-92 period this ratio increased by a slightly 
higher rate of 2.67 percent. The South was the only census region to show a slightly 
lower rate of growth from 1991 to 1992 (1.60 percent) when compared to the average 
annual rate of 1.74 percent for the prior seven years. 

As expected, the ratio of medical specialists per 100,000 beneficiaries was considerably 
higher in metropolitan than in nonmetropolitan areas. However, the differences 
between the metropohtan and nonmetropolitan areas were found to be generally lower 
than those for surgeons. MetropoHtan/nonmetropolitan differences were also found to 
be increasing during the entire 1984-92 period. In 1984, metropolitan medical 
speciahsts per 100,000 beneficiaries was 1,010 and 385 for nonmetropolitan medical 
speciahsts or 162 percent greater. This difference increased to 184 percent in 1991, and 
191 percent in 1992. 

DISCUSSION 

In the United States, the overall supply of physicians increased at a slow but steady 
pace during the period from 1984 to 1991, as measured by physician-to-Medicare 
population ratios. Total physicians per 100,000 beneficiaries rose from 1,249 in 1984 to 
1,352 in 1991. The ratio for medical speciahsts increased more than the overall growth 
rate, while the ratio for surgical speciahsts showed a nominal growth rate. These same 
general patterns continued between 1991 to 1992 showing no discernable influences of 
the MFS on physician growth, as expected in the short term. 

For every two physicians in a medical specialty in the United States during 1984-91, 
there was approximately one physician in a surgical specialty. In 1984, the ratio of 

Appendix VII-5 



medical-to-surgical specialists was 2.04; this ratio increased to 2.21 in 1991, reflecting 
an overall positive trend in the supply of medical specialists relative to surgeons for the 
seven years comprising this period. A similar small increase in the ratio of medical to 
surgical specialists occurred between 1991 and 1992, which again indicates no influences 
of the MFS payment legislation. 

Wide differences in the geographic supply of physicians existed throughout the study 
period with the Northeast and West showing much higher concentrations of physicians 
relative to the number of Medicare beneficiaries, compared with the rest of the country. 
Not only was the concentration of physicians highest in the Northeast, this ratio grew at 
a rate exceeding the national average and accelerated somewhat between 1991-1992. 
The high ratios for the West region may understate beneficiary access (as compared to 
the Northeast) because of the high geographic dispersion of both physicians and 
beneficiaries in the western States. In addition, the high ratios shown for large core 
metropolitan areas probably overstate physician supply because of the relatively larger 
service areas of physicians practicing in large cities. 

Similarly, wide differences in supply were found between urban and rural areas with 
metropolitan areas possessing much greater concentrations of physicians than 
nonmetropolitan areas. The lowest ratios occurred in thinly populated areas, 
particularly for surgeons. In addition, metropolitan area physicians per 100,00 Medicare 
beneficiaries increased modestly throughout the 1984-91 period and continued to 
increase into the beginning of 1992, while the ratios for nonmetropolitan physicians 
showed only nominal growth during the 1984-91 comparison period and a slight 
decrease from 1991 to 1992. 

The ratios for medical specialists per 100,000 beneficiaries were much larger than those 
for surgeons. The greatest differences between medical specialists and surgeons per 
100,000 beneficiaries was in rural areas. For example, in 1991, thinly populated 
nonadjacent areas had 224 medical specialists per 100,000 beneficiaries compared to 39 
surgeons per 100,000 beneficiaries, i.e., for every surgeon practicing in these areas there 
were about six medical specialists. In contrast, large core metropolitan areas had 1,429 
medical specialists and 644 surgeons per 100,000 beneficiaries or between 2 to 3 
medical specialists per surgeon. Little change occurred in this pattern from 1991 to 
1992. 

Surgeons per 100,000 beneficiaries in metropolitan areas exceeded those in 
nonmetropolitan areas by over 200 percent throughout the 1984-91 period. From 1991 
to 1992 this difference increased slightly from 221 percent to 224 percent. Differences 
between the number of metropolitan and nonmetropoHtan medical specialists were 
considerably less, but grew at a faster rate widening this difference in concentration. In 
1984, metropolitan medical specialists exceeded their nonmetropolitan counterparts by 
162 percent. This difference grew to 184 percent in 1991 and 191 percent in 1992, 
continuing the trend seen in the prior seven years. 

Appendix VII-6 



Physician-to-population ratios are an acknowledged indicator of "potential" access. 
However, possible impacts of physician payment reform on physician supply are likely 
to occur as long-term changes when compared with its effects on service delivery 
patterns. As the MFS continues, it will be important to identify changes that may occur 
in physician-to-population ratios, and to monitor beneficiary utilization and access to 
services, particularly for rural areas. 



Appendix VII-7 



Table VII-1. Specialties used in physician-to-Medicare population ratio 
calculations 



Primary Care and Medical 



Surgical 



Allergy 

Anesthesiology 

Cardiovascular Disease 

Diagnostic Radiology 

Emergency Medicine 

Family Practice 

Gastroenterology 

General Practice 

Internal Medicine 

Neurology 

Nuclear Ivledicine 

Occupational Medicine 

Pathology 

Physical Medicine and Rehabilitation 

Psychiatry 

Pulmonary Disease 

Radiology 

Therapeutic Radiology 



Colon/Rectal Surgery 
Dermatology 
General Surgery 
Neurological Surgery 
Obstetrics-Gynecology 
Ophthalmology 
Orthopedic Surgery 
Otolaryngology 
Plastic Surgery 
Thoracic Surgery 
Urology 



NOTES: Surgical specialties are based upon those specialties considered as "surgical" in the December 2, 
1993, Federal Register Vol. 58 (230). Some of the surgical specialties referenced in this Federal 
Register notice were not included in the above list because they were either limited license 
(non-MD) practitioners or could not be identified in the ARF. These include oral surgeons, 
podiatrists, hand surgeons, and multispecialty clinics. Otorhinolaryngologists are among the 
surgical specialties in the Federal Register notice but are not specifically referenced in the ARF. 
Otolaryngologists were substituted for this specialty. 



Table VII--2. Medical and surgical specialist supply trends, U.S. 1984-92 



1984 1985 1986 1987 1988 1989 1990 1991 1992 

Total Physicians 362,063 371,947 381,833 393,996 409,277 421,587 429,471 443,027 456,585 

Medical Specialists 243,051 250,590 258,130 268,415 280,286 289,312 295,471 306,152 316,834 

Surgical Specialists 119,012 121,357 123,703 125,581 128,991 132,275 134,000 136,875 139,751 

Ratio of Medical 

to Surgical Specialists 2.04 2.06 2.09 2.14 2.17 2.19 2.21 2.24 2.27 



SOURCE: Derived from tables prepared by Project HOPE: based on the Area Resource File and HCFA 
Denominator File. 



Table VII-3. Total physicians per 100,000 Medicare beneficiaries, by region, U.S. 1984-92 























Average annual 






















percent change 




1984 


1985 


1986 


1987 


1988 


1989 


1990 


1991 


1992 


1984-91 


1991-92 


U.S. Total 


1,249 


1,259 


1,267 


1,282 


1,313 


1,332 


1,334 


1,352 


1,370 


1.14 


1.33 


Region 






















': 


Northeast 


1,400 


1,415 


1,432 


1,468 


1,515 


1,549 


1,560 


1,595 


1,628 


1.88 


2.07 


Midwest 


1,101 


1,106 


1,112 


1,118 


1,143 


1,156 


1,155 


1,173 


1,189 


0.91 


1.36 


South 


1,108 


1,121 


1,133 


1,153 


1,180 


1,193 


1,194 


1,208 


1,222 


1.24 


1.16 


West 


1,544 


1,546 


1,533 


1,525 


1,552 


1,575 


1,577 


1,580 


1,589 


0.33 


0.57 


Metropolitan Areas 


1,515 


1,525 


1,534 


1,555 


1,593 


1,617 


1,621 


1,646 


1,672 


1.19 


1.58 


Large Metro. Core 


1,867 


1,882 


1,895 


1,933 


1,988 


2,020 


2,031 


2,073 


2,119 


1.51 


2.22 


Large Metro. Fringe 


1,380 


1,394 


1,411 


1,434 


1,475 


1,508 


1,516 


1,538 


1,559 


1.56 


1.37 


Medium Metropolitan 


1,305 


1,311 


1,317 


1,331 


1,361 


1,378 


1,383 


1,399 


1,416 


1.00 


1.22 


Lesser Metropolitan 


1,190 


1,196 


1,199 


1,199 


1,219 


1,236 


1,230 


1,242 


1,257 


0.62 


1.21 j 


NonmetropoUtan Areas 


545 


552 


556 


552 


563 


569 


563 


560 


556 


0.39 


-0.71 


Urbanized Adjacent 


679 


683 


686 


676 


686 


693 


685 


680 


677 


0.03 


-0.44 


Urbanized Nonadjacent 


981 


989 


986 


985 


1,000 


1,012 


1,006 


1,009 


1,011 


0.41 


0.20 


Less Urban Adjacent 


423 


431 


438 


436 


443 


449 


443 


436 


428 


0.44 


-1.83 


Less Urban Nonadjacent 


490 


496 


498 


492 


502 


505 


500 


497 


493 


0.21 


-0.80 


Thinly Pop. Adjacent 


253 


257 


260 


263 


269 


269 


260 


257 


254 


0.24 


-1.17 


Thinly Pop. Nonadjacent 


258 


265 


270 


266 


274 


274 


270 


264 


258 


0.35 


-2.27 


Ex Ante Impact Group 






















i 


Increase 


1,191 


1,196 


1,188 


1,197 


1,220 


1,236 


1,241 


1,254 


1,265 


0.74 


0.88 


No Change 


1,092 


1,105 


1,118 


1,136 


1,166 


1,191 


1,197 


1,216 


1,234 


1.55 


1.48 


Moderate Decrease 


1,275 


1,285 


1,295 


1,315 


1,349 


1,367 


1,369 


1,394 


1,419 


1.29 


1.79 


Large Decrease 


1,386 


1,394 


1,400 


1,407 


1,437 


1,455 


1,453 


1,459 


1,470 


0.74 


0.75 



II 



NOTE: Ex Ante Impact Group refers to areas grouped according to expected changes in Medicare physician payment 
under PPR, as published in the Federal Register Vol. 56 (227). See Appendix C. 

SOURCE: Derived from tables prepared by Project HOPE: based on the Area Resource File and HCFA Denominator File. 



^ 



Table VII-4. Surgical specialists per 100,000 Medicare beneficiaries by region, U.S. 1984-92 



U.S. Total 

Region 

Northeast 
Midwest 
South 
West 

Metropolitan. Areas 
Large Metro. Core 
Large Metro. Fringe 
Medium Metropolitan 
Lesser Metropolitan 

Nonmetropolitan Areas 

Urbanized Adjacent 
Urbanized Nonadjacent 
Less Urban Adjacent 
Less Urban Nonadjacent 
Thinly Pop. Adjacent 
Thinly Pop. Nonadjacent 

Ex Ante Impact Group 

Increase 
No Change 
Moderate Decrease 
Large Decrease 



1984 1985 1986 1987 1988 1989 1990 1991 1992 



Average annual 

percent change 

1984-91 1991-92 



411 411 410 409 414 418 416 418 419 



0.24 



0.24 



446 


447 


449 


451 


459 


467 


468 


471 


474 


0.78 


0.64 


350 


349 


348 


345 


350 


352 


350 


352 


353 


0.08 


0.28 


389 


390 


391 


390 


395 


398 


395 


396 


398 


0.26 


0.51 


496 


495 


488 


481 


483 


488 


486 


484 


484 


-0.35 


0.00 


505 


504 


504 


501 


508 


512 


511 


513 


515 


0.23 


0.39 


616 


617 


617 


619 


630 


638 


639 


644 


651 


0.64 


1.09 


443 


444 


446 


444 


450 


456 


458 


460 


461 


0.54 


0.22 


449 


446 


444 


439 


444 


447 


445 


446 


447 


-0.09 


0.22 


411 


409 


407 


402 


406 


407 


400 


400 


401 


-0.38 


0.25 


160 


161 


162 


160 


162 


164 


162 


160 


159 


0.01 


-0.63 


227 


227 


226 


223 


223 


224 


219 


217 


216 


-0.64 


-0.46 


356 


354 


350 


348 


349 


351 


345 


344 


342 


-0.49 


-0.58 


101 


104 


107 


106 


108 


110 


109 


107 


105 


0.85 


-1.87 


133 


135 


136 


133 


135 


136 


134 


133 


132 


0.01 


-0.75 


28 


29 


30 


31 


31 


32 


31 


31 


30 


1.49 


-3.23 


37 


37 


37 


35 


37 


39 


39 


39 


40 


0.82 


2.56 


391 


390 


384 


381 


385 


387 


387 


389 


391 


-0.07 


0.51 


352 


353 


355 


353 


358 


365 


364 


367 


369 


0.60 


0.54 


419 


419 


419 


418 


424 


428 


426 


428 


431 


0.31 


0.70 


462 


462 


462 


458 


462 


466 


463 


461 


461 


-0.03 


0.00 



NOTE: Ex Ante Impact Group refers to areas grouped according to expected changes in Medicare physician payment 
under PPR, as published in the Federal Register Vol. 56 (227). See Appendix C. 



SOURCE: Derived from tables prepared by Project HOPE: based on the Area Resource File and HCFA 
Denominator File. 



Table VII-5. Medical Specialists per 100,000 Medicare Beneficiaries, by Region, U.S. 1984-92 



1984 1985 1986 1987 1988 1989 1990 1991 1992 



Average annual 
percent change 
1984-91 1991-92 



U.S. Total 



Region 



839 



848 



856 



873 



899 



914 918 



934 



950 



1.55 



1.71 



Northeast 


954 


967 


982 


1,017 


1,057 


1,082 


1,092 


1,124 


1,154 


2.38 


2.67 


Midwest 


751 


757 


764 


773 


793 


805 


804 


821 


836 


1.28 


1.83 


South 


719 


731 


743 


763 


785 


795 


799 


811 


824 


1.74 


1.60 


West 


1,048 


1,052 


1,045 


1,044 


1,069 


1,087 


1,091 


1,096 


1,105 


0.65 


0.82 


Metropolitan Areas 


1,010 


1,020 


1,030 


1,054 


1,086 


1,105 


1,110 


1,133 


1,156 


1.66 


2.03 


Large Metro. Core 


1,251 


1,265 


1,278 


1,313 


1,358 


1,382 


1,392 


1,429 


1,468 


1.92 


2.73 


Large Metro. Fringe 


937 


950 


964 


990 


1,025 


1,052 


1,058 


1,078 


1,098 


2.03 


1.86 


Medium Metropolitan 


856 


864 


873 


891 


917 


931 


938 


953 


969 


1.55 


1.68 


Lesser Metropolitan 


779 


786 


791 


797 


813 


829 


830 


842 


856 


1.12 


1.66 


NonmetropoUtan Areas 


385 


391 


394 


392 


400 


405 


402 


399 


397 


0.52 


-0.50 


"Urbanized Adjacent 


452 


457 


461 


453 


464 


469 


466 


463 


461 


0.35 


-0.43 


Urbanized Nonadjacent 


625 


634 


637 


637 


652 


661 


661 


665 


668 


0.89 


0.45 


Less Urban Adjacent 


322 


327 


331 


330 


335 


339 


334 


329 


323 


0.32 


-1.82 


Less Urban Nonadjacent 


357 


361 


362 


359 


366 


369 


366 


363 


361 


0.24 


-0.55 


Thinly Pop. Adjacent 


226 


228 


231 


232 


238 


237 


229 


226 


224 


0.02 


-0.88 


Thinly Pop. Nonadjacent 


222 


228 


233 


231 


237 


235 


231 


224 


218 


0.15 


-2.68 


Ex Ante Impact Group 
























Increase 


800 


806 


804 


816 


834 


849 


854 


865 


875 


1.13 


1.16 


No Change 


740 


752 


763 


783 


808 


826 


834 


850 


865 


2.00 


1.76 


Moderate Decrease 


856 


866 


876 


896 


925 


939 


942 


966 


989 


1.75 


2.38 


Large Decrease 


924 


932 


939 


949 


974 


989 


990 


998 


1,009 


1.11 


1.10 



NOTE: Ex Ante Impact Group refers to areas grouped according to expected changes in Medicare physician payment 
imder PPR, as published in the Federal Register Vol. 56 (227). See Appendix C. 



SOURCE: Derived from tables prepared by Project HOPE: based on the Area Resource File and HCFA Denominator File. 



Figure VII- 1 

Trends in total physicians per 100,000 
Medicare beneficiaries, by Census region: 1984-92 



CO 1 ,700 
I 1,600 
I 1.500 
g 1,400 
1 1.300 



c 1,200 
1 1,100 
°- 1 ,000 




1984 1985 1986 1987 



1988 1989 1990 1991 
Year 



1992 



^ Northeast + North Central ^ South -^ West 



SOURCE: Derived from tables prepared by Project HOPE; based on the ARF and 
HCFA Denominator File. 



Appendix VIII 

Access to Care Before and After Fee Schedule Implementation: 
A Physician-Based Analysis 



Prepared by: Ann Meadow, Sc.D. 

Office of Research and Demonstrations 

Health Care Financing Administration 

April 1994 

Revised May 31, 1994 



Appendix VIII 

Access to Care Before and After Fee Schedule Implementation: 
A Physician-Based Analysis 



INTRODUCTION 

This analysis is based on data from all the Medicare reimbursement claims of a set of 
physicians. Beneficiary-based claims analyses typically convey utilization patterns—the 
results of the interaction of multiple actors, including patients, providers, payors, and 
others. Though they reveal the essential bottom line of access, such analyses do not 
explain the roles of the respective participants in bringing about these patterns. In 
contrast, physician-based claims analysis can shed light on the practice decisions of 
providers specifically. 

The data in this chapter were assembled to study one-year changes in access-related 
indicators at the physician practice level. The study period covers 1991, the year 
preceding the advent of the Medicare Fee Schedule (MFS), and 1992, the first year 
under the new policy. We seek to discover any impacts on access related to the 
redistribution of reimbursements caused by the new fee schedule. The MFS capped a 
series of Medicare physician payment adjustments begun in the 1980s. 

Our rationale for selecting the physician-level measures was presented in the 1993 
Access Report to Congress. There, we designated a number of key measures for the 
study of access, including: 

1. The physician's caseload -i.e., total number of different Medicare 
beneficiaries treated in a year. Caseload is one reflection of willingness to 
see Medicare patients. 

2. The performance rate for specified procedures or services. In addition to 
adjusting caseload, a physician may respond to reduced fees by selectively 
withdrawing particular services from his/her services mix. 

3. Allowed charges per physician. Medicare revenues provide information 
about the economic importance of Medicare in the physician's practice. 

4. The assignment ratio -i.e., assigned charges as a fraction of allowed 
charges. Accepting payment on assignment is a longstanding indicator of 
physician decisionmaking related to access because it indicates the 
willingness of physicians to accept Medicare fees as payment-in-full. The 



Appendix VIII- 1 



physician sample affords measurement of assignment ratios at the 
physician level for the first time. 

We generally interpret stable or growing measurements of caseload, performance rates, 
and payments as evidence of no adverse effects; conversely, declining measurements 
may signal emerging problems. This simple interpretation is used because it is hard to 
know what would have happened in the absence of the fee schedule; very little data on 
pre-existing trends exists. 

METHODS 

Study samples 

The study's physician-based records were made possible by Medicare's use of a unique 
identifier on claims. Medicare began phasing in the identifier, called the Unique 
Physician Identification Number (UPIN), in late 1989 under provisions of the Omnibus 
Reconciliation Act of 1985 (PL 99-272), now section 1842(r) of the Social Security Act. 

The 7,361 physicians^ followed for this report were chosen randomly within 18 States, 
using Medicare's UPIN registry as the sampling frame. Most results are presented at 
the State level. We chose the 18 States because of their high UPIN reporting rates on 
Medicare physician claims.^ Together the States account for about 30 percent of Part B 
enrollment. 

Two caveats for this analysis concern the representativeness of the samples and, 
potentially, the completeness of the claims histories. First, important regions-New 
England and the mid-Atlantic ~ are not represented among the 18 State samples. 
There is only limited representation for the Midwest, North Central region, and West. 
The individual samples themselves may depart somewhat from the random sampling 
ideal. The phase-in of the UPIN meant that some physicians did not have a UPIN at 
the start of 1991 and therefore were dropped from the study. Physicians without claims 
in one of the two years were also deleted, primarily because we could not ascertain why 
no claims entered the National Claims History.^ 

Second, based on anecdotal evidence and monitoring of UPIN reporting rates, we 
recognize the possibility that individual physician claims histories are not always 
complete." We have proceeded on the assumptions that missing claims affect physicians 
randomly, and are not associated with time. If these assumptions hold, then the overall 
analysis should produce reliable evidence, at least for the kinds of areas represented by 
the study States. 



Appendix VIII-2 



Variables 

Medicare Part B claims for the sample contain information about the beneficiary, the 
provider, the amount and types of care delivered, the delivery setting, and the date of 
delivery. 

Selected descriptors were retained for the present study. Patient data include the 
Health Insurance Claim Beneficiary Identification Code (HICBIC) and race. In the 
analysis, enumeration of patients seen by each physician is based on the HICBIC.^ 
HCFA databases identify the beneficiary's race using four categories: white, black, 
other, and unknown.* 

Physician descriptors include the specialty and Medicare physician participation status. 
Specialties in the analytic sample cover 43 detailed categories.' From these categories 
we created six major classes for analysis purposes: primary care, surgery, medical 
subspecialties, mental health, radiology/anesthesia/pathology, and limited license 
practitioners (optometry, podiatry, and chiropractic). Medicare physician participation 
status describes whether the physician is a member of the Participating Physician 
Program or, if not, whether the physician accepted assignment on the claim. 

Service descriptors include the type of service, the number of services, and the allowed 
charges. The typology for services comes from a classification system of more than 100 
detailed categories and 28 major categories.® This year's analysis is conducted primarily 
in terms of the 28 major categories. 

Analysis methods 

The general approach to analysis is a paired-sample comparison of 1991 and 1992 
means for the physician samples. The design uses the physician as his or her own 
control, so statistical tests for correlated data were used. 

Note that a patient is defined from the perspective of the physician; therefore, a patient 
is counted as a distinct individual each time he or she participates in a patient 
relationship with a sample doctor within a year.' 

For judging MFS effects, the design is limited by the absence of accurate measures of 
price changes confronting the individual physician. For comparison purposes, the tables 
display HCFA's estimates of the difference between MFS prices and prices projected 
assuming the former, reasonable charge system was continued.'" The percent 
differences in average price per service for the 18 study States ranged from percent 
to -10 percent. 



Appendix VIII-3 



Unless otherwise noted, we cite differences in means only when they are statistically 
significant." However, failure to mention a difference does not necessarily imply that it 
did not reach statistical significance.^^ No tests were done on changes in medians or in 
an entire distribution, although several shifts are noted. 

RESULTS 

Physician caseload 

Caseload by State 

With the implementation of the MFS, payment for most EKG interpretation services 
was bundled into visit fees. As a result, many patients whose sole service from a given 
physician was an EKG interpretation could not be counted in 1992. Therefore, we 
computed two estimates of caseload change, a lower-bound estimate and an upper- 
bound estimate (Table VIII- 1). Eliminating the EKG-only patients yields an upper- 
bound estimate; this method assumes that change in caseload for all other types of 
patients (i.e., all patients except EKG-only) provides a realistic estimate of overall 
caseload change. 

The lower-bound estimates suggest that in general, the average number of patients 
treated by each physician remained flat or grew very modestly. Two States, Kansas and 
Tennessee, had average increases of at least 32 and 20 patients (or 10 and 5 percent 
gains, respectively). Physician fees per service in these States were expected to fall by 
3 percent. On the other hand, Indiana and Oklahoma physicians registered decreases 
of 18 and 21 patients (a 5 percent decline in the mean). Relative to a continuation of 
the previous charge-based system, estimated average prices in these two States were 
expected to decrease by 2 percent. 

The upper-bound estimates suggest noticeably stronger caseload growth. Mean 
caseload rose by at least 20 and as many as 41 patients in 8 States: Nevada, Arizona, 
Alabama, Kansas, Tennessee, North Carolina, Kentucky, and Utah. Three additional 
samples had statistically significant increases of 10 to 14 patients. The mean caseloads 
increased between 4 and 13 percent. As with the earlier set of estimates, Indiana and 
Oklahoma physicians' caseload change trailed the others' considerably, but their results 
were not statistically significant. 

Pre-MFS caseloads in the study States generally averaged between 250 and 450 patients 
per physician. But Alaska's levels were only about 100 patients, very likely reflecting a 
relative scarcity of elderly and disabled beneficiaries in the population. The median 
number of Medicare patients in 1991 ranged from 63 in Alaska to 324 in Alabama. 



Appendix VIII-4 



Distributions of caseload per physician 

Caseloads are highly variable and a few physicians have very large Medicare practices. 
Annual caseload for an individual physician can be as small as one patient and as large 
as several thousand patients. 

We explored sources of growth in caseload by charting percentiles and their changes. 
For Kansas, Tennessee, Indiana, and Oklahoma, Figures VIII- 1 to VIII-4 depict the 
caseload values at 20 percentiles for both years (top graph) and the difference between 
the caseload values for corresponding percentiles in 1991 and 1992 (bottom graph). 
Based on the upper-bound estimates, the figures illustrate that the two high-growth 
States (Kansas and Tennessee) experienced caseload gains throughout nearly all of the 
distribution. This pattern is fairly representative of most of the remaining States. In 
the no-growth States (Indiana and Oklahoma), we observe both gains and losses 
occurring in various parts of the distribution. 

Caseload by specialty 

Specialty groups and their average caseloads in 1991 and 1992 are shown in Table 
VIII-2^, which presents the upper-bound estimates of caseload." Average caseloads 
vary considerably. In 1991 primary care physicians averaged 277 patients, whereas 
specialists like pathologists and radiologists treated three to five times that many on 
average. Psychiatrists, obstetrician/gynecologists, and pediatricians had relatively small 
caseloads, as did some of the limited license practitioners (dentists and chiropractors). 

Primary care physicians' mean caseload grew 4 percent overall. Psychiatrists and the 
grouping of anesthesiologists, pathologists, and radiologists added about 8 percent more 
patients on average, although the mean for pathologists alone changed little. Limited 
license practitioners as a whole added 5 percent more patients, but this gain was due to 
optometrists (+8 percent) and chiropractors (+5 percent). 

Physicians in the medical subspecialties treated 6 percent more patients on average. 
Cardiologists, despite being most affected by the EKG interpretation bundling, 
registered a possible 13 percent gain in caseload after eliminating EKG-only patients.^ 
Internists were also often impacted by the bundling, but nevertheless may have added 4 
percent more patients. 

Surgery specialists treated 5 percent more patients on average, with urologists 
registering particularly large increases of about 10 percent. The caseload for general 
surgeons, on the other hand, appears flat over the two years. 



Appendix VIII-5 



Table VIII-2 also displays estimates of the average price difference between the new 
and old payment method for selected detailed specialty groups. The percent changes in 
caseload do not appear related to the percent differences in price. 

Caseload by race 

Because of concern that minority patients might be particularly vulnerable to 
unfavorable fee schedule effects, we examined several indicators by race. Table VIII-3, 
of upper-bound estimates, shows the changes in caseload by the patient's race. 

Caseload changes for white patients are similar to the findings on overall caseload; nine 
of the 11 States with overall growth registered statistically significant gains in white 
patients. The median number of white patients declined between 1 and 6 patients in 
Arizona, Indiana, Texas, and Oklahoma, and increased by up to 30 patients in the 14 
other States.^* 

Five of the 11 growth States and one additional State, Oregon, had increases in the 
mean number of black patients. Average increases ranged from less than one patient 
in Utah to more than 5 patients in North Carolina. The median number of black 
patients declined by one patient in Florida, Texas, and Oklahoma, remained unchanged 
in 8 States, and increased by 1 to 2 patients in the remaining 7 States (Alabama, 
Arizona, Indiana, Nevada, North Carolina, South Carolina, and Tennessee). 

In virtually all States the average number of patients in the "other" and in the 
"unknown" categories grew at double-digit percentage rates. Note that the base-year 
caseload levels are usually quite small. 

A further indicator developed for black patients was the number of physicians having at 
least one. In most States the number of physicians with at least one black patient 
increased slightly but not significantly (Table VIII-4). In addition, we tested the ratio of 
black patients to the sum of white and black patients. This proportion declined by a 
very small margin of approximately 0.5 percentage points in Texas and Alaska. 

Despite the small shift in the white-black balance in Texas and Alaska, we found no 
difference between the caseload change that one would expect from enrolhnent growth 
and the change actually observed. In Kansas, North Carolina, and Utah, caseload 
growth outpaced enrollment growth for black patients. Elsewhere, it appeared to keep 
up with enrollment growth. 

For patients in the "other" racial category, the comparison suggested that patient growth 
generally kept up with enrollment growth, except in Arizona, Hawaii, Kansas, North 
Carolina, Tennessee, and Utah, where enrollment growth was exceeded. Among 



Appendix VIII-6 



physicians in Arizona, Alabama, Kansas, North Carolina, Tennessee, Kentucky, and 
Utah, the growth in white patients exceeded enrollment growth. 

Performance rates for detailed procedures groups 

To study services that may be particularly sensitive to adverse access impacts, we 
looked at change in the performance rate for 44 detailed procedure categories. The 
MFS shifted Medicare fees away from these surgical and other procedure categories, in 
favor of evaluation and management services like office visits and consultations. 
Overall, among the 7,361 physicians, 18 procedure groups had more performers in 1992 
and 26 had fewer. However, most alterations in the number of performers were within 
±1 percent, and only 6 were statistically significant^^ (Figures VIII-5 and VIII-6). There 
were fewer performers for hip fracture repair operations (478 performers in 1991 and 
442 in 1992); ambulatory inguinal hernia repair (540 in 1991 and 500 in 1992); and 
miscellaneous minor procedures not priced under the fee schedule (1,851 in 1991 and 
1,605 in 1992). A number of procedures were subject to coding changes that could 
have caused losses in performers from the non-MFS minor procedures category. ^^ 
More physicians provided cataract operations (246 in 1991 and 325 in 1992); 
musculoskeletal ambulatory procedures (1104 in 1991 and 1170 in 1992); and 
laparoscopic cholecystectomy (361 in 1991 and 438 in 1992). 

Allowed charges per physician 

Allowed charges per physician by State 

The average allowed charges per physician increased in five study States: Kansas, 
Kentucky, Utah, Idaho, and North Carolina (Table VIII-5). The average increase 
ranged from $1,963 in Idaho (where the average price change expected, percent, was 
the most favorable among the States studied), to $8,444 in Kansas (where the average 
price change expected was -3 percent). Percentage increases in the five States ranged 
from 4 percent, in Idaho, to 11 percent, in Kansas. 

The average allowed charges declined in one State, Nevada. The estimated average 
reduction was $5,461, or 6 percent. At the same time, change in the median allowed 
charges in Nevada was negligible. Nevada physician service fees were expected to 
decline by 9 percent. Evidence of an average decrease in one additional sample, 
Texas's, was of borderline statistical significance. In Texas, Arizona, and Florida, 
median allowed charges declined by $3,400 to $3,800. 

Allowed charges per physician by specialty 

Primary care physicians and limited license practitioners had increases in mean allowed 
charges amounting to $3,677 (10 percent increase) and $625 (5 percent increase), 

Appendix VIII-7 



respectively (Table VIII-6 and Figure VIII-7). But the gain for many primary care 
physicians was considerably smaller than $3,677, since the median difference was 
$1,680. Two detailed specialty groups within these aggregates had notably higher 
percentage changes in the mean-optometrists ($1,343, or 15 percent increase) and 
chiropractors ($890, or 16 percent increase). Podiatrists, who are here classified as 
LLPs but grouped with surgeons for purposes of monitoring volume performance, 
experienced a $3,083 decline (-6 percent) in mean allowed charges. 

Only one of the six broad specialty groups, surgery specialties, had lower allowed 
charges in 1992-a decline of $2,938 per physician, or 3 percent. However, within the 
surgery aggregate, general surgeons experienced an estimated average decline of $9,972, 
or 11 percent; the median for this group decreased $7,900. 

Among the detailed specialties, about half registered declines in the mean, and half 
gains. But most changes were within 10 percent and few were statistically significant. 
Statistically reliable were gains for internal medicine specialists, who billed $3,654 more 
(4 percent increase), and pediatricians, $1,171 more (18 percent increase). In both 
cases, however, the median fell slightly. 

Distributions of allowed charges per physician 

Figure VIII-8 provides information about changes in the distribution of allowed charges 
per physician. In Texas, Oklahoma, and the 5 highest-impact States-Alaska, Nevada, 
Florida, Hawaii, and Arizona-more physicians had allowed charge losses exceeding 10 
percent than had allowed charge gains greater than 10 percent. In the remaining 
States, gains larger than 10 percent were up to twice as frequent as losses of the same 
magnitude. Throughout the sample States, extreme losses (greater than 50 percent) 
were rarer than extreme gains, as shown by the shaded ends of the bars in 
Figure VIII-8. Physicians with small caseloads are the ones most likely to experience 
abrupt changes in allowed charges. 

Technical Note VIII-A presents further information about changes in allowed charges, 
by examining charges according to the type of service. The results reflect Medicare's 
intended policy of shifting payments towards evaluation and management services. 

Assignment rates 

Assignment rates by State 

By accepting assignment, the physician agrees to accept the Medicare-determined 
charge as payment in full. Assignment enhances access because it can result in more 
predictable, often lower expenses for medical services. Physicians who join Medicare's 
Participating Physician program agree to take assignment on all their claims. 

Appendix VIII-8 



From the physician's point of view, joining as a Participating Physician means a slightly 
higher Medicare insurance reimbursement compared to non-Participating Physicians who 
accept assignment. When not accepting assignment the non-Participating Physician's full 
fee is subject to a ceiling. Although such limits on "extra billing" were introduced in 
1987 and tightened in 1991, in the first year of the fee schedule the limit was reduced 
once again. As a result. Medicare expected more physicians to join the Participating 
Physician Program and to accept assignment. 

In 1991 assignment ratios'' ranged from 32 percent in Idaho to 97 percent in Nevada 
(Table VIII-7). Seven States had an overall assignment ratio of 85 percent or more. 
By 1992 assignment ratios increased by between 1 and 7 percentage points,^" so that the 
range was 38 percent to 98 percent; in 11 States the ratio was 85 percent or more. 
The States with the lowest assignment ratios tended to have the largest increases. 

Assignment ratios by race of patient 

Table VIII-8 shows the 1991 and 1992 assignment ratios according to race of the 
sample physicians' patients. In almost all State samples, assignments appear lower for 
white patients than for the other groups shown. This was especially true in 1991, when 
black beneficiaries' assignment ratio was at least 10 percentage points higher than 
whites' in 11 States. 

All race groups generally shared in the improved assignment ratios in 1992. It appears 
from these data that white beneficiaries' gains often are larger, and more are 
statistically significant. Perhaps the others are subject to a "ceiling effect" by which 
gains are increasingly limited as the upper bound (100 percent) is neared.^' 

Technical Note VIII-B, presenting assignment rates by specialty, further illustrates the 
broad-based nature of the rise in assignments. In Technical Note VIII-C, the rise in 
assignments is seen to be especially associated with certain evaluation and management 
services. 

DISCUSSION 

Our indicators of access from the physician perspective are only a rough reflection of 
physician decisionmaking, because a great deal of information about the specific 
conditions physicians face is missing. Nevertheless, the data further our understanding 
of the fee schedule's impact on access to care. 

The findings on caseload, our primary access-related measure, suggest that the first year 
of Medicare-mandated fees had no detrimental effect on physicians' wilhngness to see 
Medicare patients. Isolated declines in caseload may have occurred in two States, but 

Appendix VIII-9 



our alternative estimates are persuasive that the lower-bound reductions are overstated. 

Diverse specialty groups, such as psychiatry, gastroenterology, anesthesiology, urology, 
and optometry, experienced caseload gains of up to 10 percent or more. We found no 
tenable evidence of adverse impact on minority groups' caseload measures. We noted 
no relationship between the relative size of the caseload change and the relative price 
change forecasted by HCFA. These aggregated results remain to be further evaluated 
by microdata studies with more power to detect potential relationships. 

The caseload growth suggested by our upper-bound estimates is similar to that found in 
a study of Medicare data from Indiana in the late 1980s.^ Growth for Indiana solo 
practice physicians was 8 percent from 1988 to 1989, and 6 percent from 1989 to 1990. 
Half of our 18 States had statistically reliable caseload growth in the range of 4 percent 
to 9 percent. 

Did the Medicare Fee Schedule put particularly strong pressure on access to surgical 
services? The physician data may contain some isolated indications that this could be 
so, but the overall evidence does not. Out of 44 procedures examined, the only 
findings of note were that fewer physicians in our samples performed hip-fracture and 
hernia repairs and certain minor procedures, while more performed cataract, 
ambulatory musculoskeletal, and laparoscopic gall bladder operations. 

Coding changes may explain the reduction in some minor procedures. Regarding hip 
repair, the physician sample findings are not necessarily inconsistent with Medicare 
administrative data showing that utilization rates have increased during the study period. 
Aside from technical reasons like sampling variability and the limitations on 
generalizabihty noted in the Methods section, lower performance rates in the presence 
of higher utilization could be explained by higher caseloads for the remaining 
performers. Possible concentration of care among fewer physicians is a potential 
impact of the MPS we hope to examine in the future. The management of hernia has 
received attention by medical experts concerned with advancing standards of care. It is 
possible that fewer physicians performed hernia repairs in response to these research 
initiatives emphasizing medical management of the condition. An increase in the 
number of physicians performing laparoscopic gall bladder operations probably reflects 
a continuing diffusion of the technology. 

Mean allowed charges per physician were expected to decline in some areas and for 
certain types of specialists. Of the samples in which average price declines were 
deepest, only one, Nevada, registered a statistically reliable decline in allowed charges 
per physician. Among Alaska, Hawaii, and Florida-the other large-impact areas-only 
Florida presented mild evidence of impact on the typical reimbursement. Obviously 
some individual physicians did experience large proportional reductions in total 
reimbursements. But relative to their 1991 reimbursements, more physicians 

Appendix VIII- 10 



experienced sizable gains than sustained sizable losses. These findings suggest that the 
economic importance of Medicare in the physicians' practices as a whole probably did 
not wane, and may even have enlarged. We would be in a position to draw firmer 
conclusions on this point if data on non-Medicare reimbursements were available. 

The assignment ratios from the physician samples were consistent with national data 
showing assignments continuing their upward trend. Physicians in States with 
historically low assignment rates tended to exhibit larger increases in assignment ratios 
than others. Assignment ratio increases were particularly pronounced for office visits, 
the services group associated with entry into the health care system. Payment policy 
under the fee schedule was to increase fees for these services in many areas. The 
accompanying growth in visit-fee assignments may have served to counteract potential 
adverse impacts on access caused by the uptrend in office visit fees. 

The results of this study are not unexpected, especially in view of the fact that we 
studied only the first year of the 5-year phase-in of the MFS. During the period, the 
size of price changes varied among procedures, physicians, and localities. The transition 
was designed so that the most change occurred in the first year. The complicated price 
adjustments were accompanied by some degree of uncertainty. Survey findings of the 
Physician Payment Review Commission^ indicated that many physicians in 1992 did not 
understand major aspects of the MFS. On that basis we would expect less change in 
1992 than might ultimately occur. Moreover, it is unlikely that most physicians in the 
short term can radically adjust their practices. 

Accordingly, we would anticipate physician responses to become more definitive over 
time. Hence we shall continue to analyze access from the physician perspective. 



Appendix VIII- 11 



Acknowledgements 

The author wishes to thank James Beebe for his statistical advice. Sherry Reich 
assisted with table and chart production and Thaddeus Holmes prepared the graphics. 



Appendix VIII-12 



ENDNOTES 

1. In cases where the physician practices in more than one state, the sampling units 
are the physician's practice within the state borders only. This means that a small 
number of physicians are represented more than once~one time for each of the 18 
states in which a practice exists. Also, practices in states other than the 18 included 
here undoubtedly account for some of the study physicians' activity, but we did not 
assemble claims from outside the study states. Therefore, the units of observation 
are best considered state/physician units. For the most part, the units account for 
all of a given physician's Medicare activity, but it should be recognized that the 
averages "per physician" reported herein are slight underestimates. 

2. The reporting rates were estimated from claims of a 5 percent sample of 
beneficiaries in 1991 and the first half of 1992. 

3. The restrictions on the individual samples limit somewhat the questions on Medicare 
involvement we are able to address. For example, given the restrictions, we do not 
measure nor attempt to interpret a complete absence of claims for a physician as 
a possible response to the fee schedule. The restrictions may also affect the 
generalizability of the study. For example, conceivably new physicians not eligible 
for sampling (due to the restrictions) can set up practices that draw patients away 
from the sample. In particular, if the new physicians are members of minorities or 
are women, certain beneficiaries may be attracted to them, resulting in changes for 
the sampled physicians that have nothing to do with the MFS. Aside from 
employing random sampling, another means of mitigating this kind of threat would 
be to introduce additional variables that control for market conditions. 

4. Information about possible incompleteness of the claims histories comes from two 
sources. First, October 1993 results of Medicare's UPIN monitoring, based on an 
improved methodology, suggest that nationally approximately one in five Part B 
physician line items enters the National Claims History (NCH) without a rendering 
physician UPIN. Several of the 18 states in this study now have measured reporting 
rates below 80 percent. The claims with missing UPINs are likely a mixture of 
claims from physicians who don't yet have a UPIN and claims from others who do 
have one. Second, anecdotal information from carriers indicates that, for example, 
periods of electronic systems failures may have caused claims to be forwarded to 
the NCH without the UPIN, even though the physician had obtained a UPIN. In 
order to append a UPIN the carrier must make proper identification of the 
rendering physician. To do this, the carrier relies on its traditional provider billing 
numbers or, particularly for group practice physicians, recently established 
numbering systems. The procedure does not always result in an appended UPIN. 
For example, a carrier may erroneously process a bill under a non-UPIN-related 

Appendix VIII- 13 



billing number, which would lead to a missing UPIN, The biller itself may fail to 
provide the individual provider number of a group practice member, again leading 
to a missing UPIN. 

We do not know whether any sampled physicians are among those with incomplete 
claims histories. What would be particularly troubling is information suggesting that 
systems failures leading to incomplete claims histories were more prevalent in 1991 
than 1992. This could bias the change scores analyzed in this study in a positive 
direction. However, we have no information about the frequency over time or 
impact of systems failures. 

5. Over time, this beneficiary identifier can change as an individual assumes a new 
marital or employment status. However, we checked for the frequency of new 
identifiers among the study's claims and found it to be negligible. 

6. The small number of beneficiaries each year with more than one race among their 
claims was assigned to the "unknown" race category. 

7. Physicians with multiple specialties shown among their claims were assigned to their 
specialty of highest reimbursement. However, if the resulting specialty was "multiple 
specialty group," a specialty was found by matching the UPIN against the national 
registry file. For 44 physicians the specialty was unknown. 

8. Appendix II to this volume describes the classification rules. 

9. Depending on the state, the proportion of beneficiaries participating in no more 
than one relationship ranged between 50 percent and 90 percent; the larger states 
had the highest proportion. 

10. Federal Register 56 (227):59619-59621. November 25, 1991. These are estimates 
of the MFS effect on average prices, relative to the reasonable-charge system, and 
do not include the 1.9 percent update for 1992. If they had included this update, 
the estimates would be about 2 percent larger. 

11. Our significance criterion was the two-tailed 5 percent level unless tests were 
repeated many times, in which case the criterion was the 1 percent level. 

12. Complete test results are available from the Office of Research upon request. 

13. This table was constructed simply by regrouping individuals according to specialty; 
no weighting was done to neutralize the uneven sampling ratios across states. 

14. The only differences between the upper- and lower-bound versions of this table were 
that the lower-bound method resulted in large negative caseload changes for 

Appendix VIII- 14 



internists and cardiologists, and in smaller gains for gastroenterologists, nephrologists 
and pulmonary disease specialists. The average caseload difference for medical 
specialties as a group was -38. The lower-bound version is available upon request. 

15. We will further study changes in the services mix for the specialties with large 
changes in caseload. 

16. Results on median changes differed little between the upper-and lower-bound 
estimation methods. 

17. A conservative test criterion, the .01 significance level, two-tailed test, was used 
because of the especially large number of tests performed. 

18. Several codes~for example, involving nasal procedures-were deleted in 1992 and 
replaced by new codes that are found in another category of the 100-class system. 

19. The assignment ratio is computed within the state as the total for assigned allowed 
charges divided by the total for allowed charges. The denominator is the sum of 
allowed charges from all physicians. The numerator was derived by adding allowed 
charges from Participating Physicians to assigned allowed charges from all other 
physicians. 

20. In all but 3 States, the increase was statistically significant. 

21. We stop short of concluding that white beneficiaries tended to have larger financial 
access gains than others. A conclusion based on the tests on gains scores does not 
account for all sources of sampling variability (Guilford, J.P. 1965. Fundamental 
Statistics in Psychology and Education .). A direct test of the difference between 
gains among the groups would provide a better assessment of the relative growl;h. 
Such a test requires an estimate of correlation between gain scores. Using a 
conservative method that did not take into account correlation between the gain 
scores, we found no statistically significant difference in the ratio growth for white 
vs. black beneficiaries, except in Alabama, Florida, and Utah. 

22. Cooperative Agreement Number 17-C-90159/3, "Reasonable Charge Impact Studies," 
HK Research Corporation, Severna Park, Maryland. 

23. Physician Payment Review Commission. 1993. Annual Report to Congress. 
Washington, D.C. 



Appendix VIII-15 



TABLE VIII-1 
Mean caseload per physician and change and percent change in mean 
By state: 1991 -1992 



State 


Estimate 


b 

Expected 

Mean 

a Price 

Change (%) 


Number 

of 

Sample 

Physicians 


1991 

Mean 

Caseload 








1992 

Mean 

Caseload 


Change 

in Mean 

Caseload 


Percent 
Change 


Alaska 


lower 
upper 


-10 


263 
262 


104 
99 


109 
109 


5 
11 


4 
11 


Nevada 


lower 
upper 


-9 


394 
394 


350 
327 


353 
352 


2 
25 '• 


1 
8 


Florida 


lower 
upper 


-8 


444 
444 


455 
433 


455 
454 



21 



5 


Hawaii 


lower 
upper 


-8 


338 
338 


199 
193 


204 
203 


5 
10 * 


3 
5 


Arizona 


lower 
upper 


-6 


389 
388 


348 
328 


347 
348 


-1 
20 * 



6 


Alabama 


lower 
upper 


-4 


396 
394 


466 
444 


469 
471 


3 
27 .. 


1 
6 


Texas 


lower 
upper 


-4 


471 
470 


302 
293 


307 
307 


5 
14 * 


2 
5 


Kansas 


lower 
upper 


-3 


482 
481 


318 
310 


350 
351 


32 ** 
41 *• 


10 
13 


Tennessee 


lower 
upper 


-3 


451 
451 


367 
359 


387 
387 


20 * 
28 •• 


5 
8 


North Carolina 


lower 
upper 


-3 


462 
462 


381 
369 


399 
399 


18 
30 ** 


5 
8 


Indiana 


lower 
upper 


-2 


514 
514 


378 
359 


360 
360 


-18 * 

1 


-5 



Montana 


lower 
upper 


-2 


368 
368 


362 
357 


363 
363 


1 
6 



2 


South Carolina 


lower 
upper 


-2 


346 
346 


437 
406 


430 
430 


-6 
23 


-1 
6 


Oklahoma 


lower 
upper 


-2 


435 
435 


373 
361 


353 
353 


-21 * 
-8 


-6 
-2 


Oregon 


lower 
upper 


-2 


470 
470 


253 
241 


252 
252 



11 



5 


Kentucky 


lower 
upper 


-1 


387 
386 


380 
362 


396 
397 


16 
34 ** 


4 
9 


Utah 


lower 
upper 


-1 


402 
402 


237 
227 


255 
255 


18 •* 
28 ** 


8 

12 


Idaho 


lower 
upper 





349 
349 


303 
300 


311 
311 


9 
11 * 


3 
4 



a See text for definitions of upper- and lower-bound estimates. 

b Percent change in average price per service forecasted by HCFA in Federal Register 56(227), Nov. 25, 1991. 

* * = statistically significant at .01 level 

* = statistically significant at .05 level 



Source: HCFA Part B Monitoring System: National Claims History Physician Sample File. 



TABLE VIII-2 
Mean caseload per physician and change and percent change in mean 
By specialty group: 1991 - 1992 



a 


b 
Expected 
National 
Mean Price 


Number 

of 

Sample 














1991 


1992 Change in 


Mean 


Mean Mean 




Percent 


Specialty 


Change(%) 


Physicians 


Caseload Caseload Caseload 




Change 




Primary Care 


n/a 


1578 


277 


289 


12 


*« 


4 


Family Practice 


15 


916 


277 


287 


10 


* * 


4 


General Practice 


17 


657 


275 


289 


14 


* 


5 


Psychiatry 


-2 


306 


64 


69 


5 


* 


8 


Medical Specialties 


n/a 


1604 


374 


396 


22 


* * 


6 


Allergy/Immunology 


n/a 


36 


92 


102 


10 




11 


Physical Medicine 


n/a 


32 


185 


195 


10 




6 


Pediatrics 


n/a 


71 


39 


41 


2 




6 


Gastroenterology 


-10 


93 


421 


458 


37 


* * 


9 


Cardiology 


-9 


210 


577 


653 


76 


* * 


13 


Nephrology 


-6 


43 


328 


355 


28 


* * 


8 


Neurology 


-4 


101 


365 


363 


-2 







Pulmonary Disease 


-3 


62 


437 


462 


25 


* 


6 


Internal Medicine 





915 


371 


384 


13 


* * 


4 


RARc 


n/a 


798 


774 


836 


62 


* * 


8 


Anesthesiology 


-11 


354 


204 


226 


22 


* * 


11 


Pathulogy 


-10 


103 


781 


796 


15 




2 


Radiology 


-10 


338 


1,373 


1,492 


119 


* * 


9 


Surgery 


n/a 


1994 


291 


305 


13 


* * 


5 


Obstetrics/Gynecology 


n/a 


417 


66 


70 


4 


* « 


7 


Oral Surgery (Dentist) 


n/a 


65 


17 


18 


2 




11 


Thoracic Surgery 


-14 


69 


235 


244 


9 




4 


Ophthalmology 


-11 


214 


795 


835 


40 


* 


5 


Neurosurgery 


-10 


69 


155 


163 


7 




5 


General Surgery 


-8 


373 


239 


241 


2 




1 


Orthopedic Surgery 


-8 


324 


235 


246 


12 


* * 


5 


Plastic Surgery 


-8 


63 


124 


129 


5 




4 


Urology 


-6 


130 


494 


545 


51 


* * 


10 


Dermatology 


-1 


116 


643 


663 


20 




3 


Otolaryngology 


2 


141 


293 


303 


10 




4 


LLP 


n/a 


1030 


118 


123 


6 


** 


5 


Podiatry Surgery 


6 


113 


396 


403 


7 




2 


Chiropractic 


12 


529 


45 


47 


2 


4 * 


5 


Optometry 


20 


388 


135 


146 


11 


* * 


8 



Source: HCFA Part B Monitoring System: National Claims History Physician Sample File. 
NOTE: Data derived from upper-bound estimation method; see text for definition. 

LLP = Limited License Practitioners; Oral Surgeons (Dentists) are also LLP but included with 
Surgeons for this analysis 
a Data for the six broad specialty groups may include physicians in detailed specialties not shown, 
b Percent change in average price per service forecasted in Federal Register 56(227), Nov. 25, 1991. 
c Subtotal for radiology, anesthesiology, and pathology. 
** = statistically significant at .01 level 
* = statistically significant at .05 level 
n/a = not available 



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Table VIII-6 
Mean allowed charges per physician and change and percent change in mean 
By specialty group: 1991 - 1992. 





b 
Expected 


Number 


1991 


1992 








National 


of 


Mean 


Mean 


Change in 




a 


Mean Price 


Sample 


Allowed 


Aliowed 


Mean Allowed 


Percent 


SpeciaJty 


Change <%) 


Physicians 


Charges 


Charges 


Charges 


Change 1 


Primary Care 


n/a 


1579 


$37,362 


$41,039 


$ 3,677 ** 


10 


Family Practice 


15 


916 


40,235 


44,217 


3,982 " 


10 


General Practice 


17 


658 


33,364 


36,603 


3,239 ** 


10 


Psychiatry 


-2 


306 


19,753 


21,764 


2,011 


10 


Medical Specialties 


n/a 


1610 


111,686 


114,041 


2.356 


2 


Allergy/Immunology 


n/a 


36 


18,391 


23,820 


5,428 ** 


30 


Physical Medicine 


n/a 


32 


52,396 


56,049 


3.653 


7 


Pediatrics 


n/a 


73 


6,519 


7,690 


1,171 * 


18 


Gastroenterology 


-10 


93 


157,680 


152,084 


- 5,596 


-4 


Cardiology 


-9 


212 


217,537 


221,450 


3,913 


2 


Nephrology 


-6 


43 


192,054 


193,290 


1,236 


1 


Neurology 


-4 


101 


71,001 


64,377 


- 6,625 


-9 


Pulmonary Disease 


-3 


62 


135,552 


133,313 


- 2,239 


-2 


Internal Medicine 





917 


98,587 


102,241 


3,654 * 


4 


RAP\c 


n/a 


798 


76.901 


78,446 


1,546 


2 


Anesthesiology 


-11 


354 


49,632 


49,006 


- 626 


-1 


Pathology 


-10 


103 


60,085 


63,397 


3,312 


6 


Radiology 


-10 


338 


111,005 


114,385 


3.379 


3 


Surgery 


n/a 


1994 


97,020 


94,082 


- 2,938 '* 


-3 


Obstetrics/Gynecology 


n/a 


417 


9,879 


9,714 


- 165 


-2 


Oral Surgery (Dentist) 


n/a 


65 


3,238 


2,802 


- 436 


-13 


Thoracic Surgery 


-14 


69 


232,038 


226,249 


- 5,789 


-2 


Ophthalmology 


-11 


214 


266,963 


263,707 


- 3,256 


-1 


Neurosurgery 


-10 


69 


88,531 


83,144 


- 5,387 


-6 


General Surgery 


-8 


373 


92,426 


82,454 


- 9,972 ** 


-11 


Orthopedic Surgery 


-8 


324 


95,978 


93,256 


- 2,722 


-3 


Plastic Surgery 


-8 


63 


53,050 


49,472 


- 3,578 


-7 


Urology 


-6 


130 


168,929 


175,410 


6,480 


4 


Dermatology 


-1 


116 


104,593 


103,204 


- 1,389 


-1 


Otolaryngology 


2 


141 


45,048 


44,081 


- 967 


-2 


LLP 


n/a 


1030 


11,992 


12,616 


625 ** 


5 


Podiatry Surgery 


6 


113 


52,214 


49.131 


- 3,083 * 


-6 


Chiropractic 


12 


529 


5,710 


6,600 


890 ** 


16 


Optometry 


20 


388 


8,842 


10,185 


1,343 ** 


15 



Source: HCFA Part B Monitoring System: National Claims History Physician Sample File. 

NOTE: LLP = Limited License Practitioners; Oral Surgeons (Dentists) are also LLP but included with 

Surgeons for this analysis, 
a Data for the six broad specialty groups may include physicians in detailed specialties not shown, 
b Percent change in average price per service forecasted by HCFA in Federal Register 56(227), Nov. 25, 1991. 
c Subtotal for radiology, pathology, and anesthesiology. 

* * = statistically significant at .01 level 

* = statistically significant at .05 level 
n/a = not available 






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m 
C 

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^ o 

i» 



Konsos 

No. of potients ot selected percentiles 




■ I' " I " ■ ! ' "I" " I " "!' " I ' 
5 I 1£ I 25 I 35 I 45 I 55 I 65 I 75 I 85 I 95 

10 20 30 40 50 60 70 80 90 100 
Percentile 



1991 



1992 



400 



350 



300 - 



250 - 



200 - 



150 - 



TOO - 



50 - 



-50 



Dltterence between percentile points 




5 I 15 I 25 1 35 1 45 | 55 I 65 I 75 I 85 | 95 | 
10 20 30 40 50 60 70 80 90 100 

Percentile 



SOURCE: National Claims History Physician Sample File. 



^ in 

-D 



170 

leo 

150 
1«0 
120 
120 
110 
100 
90 

eo 

70 

60 

50 

40 

30 

20 

10 



-10 

-20 



Figure VIII-2 

Tennessee 



No of potlerls ot selecteO percentiles 




5 I 15 I 25 I 35 I 45 I 55 I 65 
10 20 30 40 50 60 70 

Percentile 



80 



65 I 95 I 
90 100 



1991 1^^^ 1992 
Ditference between pe'certlle points 




5 I 15 I 25 I 35 I 45 I 55 I 65 I 
10 20 30 40 50 60 70 

Percentile 



80 



65 I 95 I 
90 100 



SOURCE: National Claims History Physician Sample File. 



Figure VIII-3 



Indiana 



■i » 
a. c 
^ 
0" 

1. c 
» X 

£ I- 



-100 



No. o< potrer.ts ot selected percentiles 




5 I 15 
10 20 



I 35 I 45 I 55 I 65 I 75 I 65 I 95 I 
30 40 50 60 70 80 90 100 

Percentile 

t8^ 1991 R^^ 1992 
Di<ference between percentile points 




-I 1 1 1 1 1 1 1 1 1 1 1 1 1 r 1 r 

5 I 15 I 25 I 35 I 45 I 55 I 65 I 75 I B5 I 95 

10 20 30 40 50 60 70 80 90 100 

Percentile 



SOURCE: National Claims History Physician Sample File. 



Figure VIII-4 

Oklahoma 



No. of potients ot selected percenliles 




Percentile 
1991 P^^^^ 1992 



ISO 
170 
160 
150 
14C 



Difference between percentile points 



no p 
100 



90 
80 
7C 
60 
50 

40 - 

30 - 

20 - 

10 - 



-10 - 

-20 - 

-30 - 

—A 




5 I 15 I 25 I 35 i 45 I 55 I 65 i 75 I 85 I 95 I 
10 20 30 40 50 60 70 80 90 100 

Percentile 



SOURCE: National Claims History Physician Sample File. 



Figure Vm-5 

Percent change in number of physicians performing 
each type of procedure: 1991-1992 



Miior-tsMiil 


^ 


■ 


Major and Eye procedures 

■ 




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-10 



10 



15 



20 



25 



30 



35 



Percent change 



* = Test of 1991 - 1992 difference in proportion of physicians performing 
the procedure is significant at .01 level. 



SOURCE: National Claims History Physician Sample File. 



Figure Vm-6 

Percent change in number of physicians performing 
each type of procedure: 1991-1992 

AmbLdatory and other procedures 



MnbuHioip^win 


R^ 




/WntMHUKUkakaMii • 


■■■■■■ 


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-10 



-5 



10 



15 



20 



25 



Pofcsnt chsngo 



* _ 



Test of 1991 - 1992 difference in proportion of physicians performing 
the procedure is significant at .01 level. 



SOURCE: National Claims History Physician Sample File. 



Figure Vm-7 

Mean allowed charges per physicians 
by specialty: 1991 and 1992 



Percent Change 



$140,000 
$120,000 - 
$100,000- 
$80,000 - 
$60,000 - 
$40,000 - 
$20,000 



$0 



10% 



2% 



$111,686 «"*'0*1 



$37,362 



$41,039 





Primary Care 



Medical Spec. 



E]l991 11992 



-3% 



$97,020 



$94,082 




Surgery 



SOURCE: National Claims History Physician Sample File. 



Figure Vm-8 

Percent of physicians who have greater than 10 percent 
loss or gain in Medicare allowed charges 



Loss 



State 



Gain 



43./ i^^i^ 


Alaska 

r4evada 

Fkxida 

Hawaa 

Anzona 

Aiabama 

Texas 

Kansas 

Tennessee 

Nonti Carottna 

Indiana 

Montana 

Soutn Carolina 

Oklahoma 

Oregon 

Kentucky 

Utah 

Idaho 


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40 30 20 10 



10 20 X 40 



50 



> 10% -50% loss 

> 50% loss 



> 10% -50% gain 

> 50% gain 



SOURCE: HCFA National Claims History Physician Sample File. 



TECHNICAL NOTES TO 
APPENDIX VIII 



TECHNICAL NOTE VIII-A 

Allowed Charges per Physician by Type of Service 

Office visits and consultations, and to a lesser extent, hospital visits, were by and large 
the main sources of allowed charge growth for the sample physicians (see accompanying 
table). For office visits, whose allowed charges per physician usually average between 
$5,000 and $10,000, increases between 10 percent and 20 percent occurred in most 
samples. Nevada, where average fees per service were predicted to dechne by 9 
percent, had a small decline of 3 percent in average office visit allowed charges; this 
drop could have resulted from sampling variability. Changes in Medicare billing policy 
contributed to the growth in consultation charges. 

Mean allowed charges for major procedures, which account for a large fraction of the 
total, generally declined by between 10 percent and 20 percent, but few changes 
exceeded the range of statistical variability. Similarly, the means for anesthesia, 
endoscopy, cardiovascular procedures, orthopedic procedures, and ambulatory 
procedures tended to decline but the percent changes were often smaller; again, few 
changes were statistically reliable. (The significance criterion was .01.) 

When we examined allowed charges per performer, the basic results usually did not 
change. For eye procedures, however, which are performed by fewer than 40 
physicians per sample, in 15 States, performers took in lower allowed charges on 
average, but statistically the losses were not reliable. For hospital visits, the statistical 
results were stronger when considering only performers as opposed to all sample 
physicians. 



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TECHNICAL NOTE VIII-B 

Assignment Ratios by Specialty 

Assignment ratio increases were not confined to any particular specialty (see 
accompanying table). Assignment ratios for the six broad specialty groups increased by 
2 to 7 percentage points between 1991 and 1992. Limited license practitioners, the 
group with the lowest ratio, had the smallest increase. Radiologists, anesthesiologists, 
and pathologists had the largest increase. 

Examination of detailed specialties suggested that assignment ratio increases were very 
widespread, although a number of gains that are small or based on smaller samples 
were not statistically significant. Nevertheless, reliable growth in the ratio occurred in 
several high-assignment specialties (e.g., pulmonary disease, plastic surgery, optometry), 
as well as several low-assignment ones (e.g., urology, orthopedic surgery, pathology). 



TECHNICAL NOTE TABLE VIII-B-1 
Ratio of assigned allowed charges to total allowed charges 
And change and percent change in ratio 
By specialty group: 1991 - 1992 





b 
Expected 


Number 










' 


National 


of 


1991 


1992 




Percent 


a 


Mean Price 


Sample 


Assignment 


Assignment 


Change 


Change in 


:|^ecialty 


Change (%) 


Physicians 


Ratio 


Ratio 


in Ratio 


Ratio 


Primary Care 


n/a 


1579 


0.79 


0.82 


0.03 •• 


4 


Family Practice 


15 


916 


0.76 


0.80 


0.04 ** 


5 


General Practice 


17 


658 


0.82 


0.85 


0.03 ** 


3 


Psychiatry 


-2 


306 


0.84 


0.88 


0.04 •* 


5 


Medical Specialties 


n/a 


1610 


0.82 


0.85 


0.03 ** 


4 


Allergy/Immunology 


n/a 


36 


0.62 


0.62 


0.00 


1 


Physical Medicine 


n/a 


32 


0.89 


0.94 


0.05 


6 


Pediatrics 


n/a 


73 


0.91 


0.95 


0.04 


4 


Gastroenterology 


-10 


93 


0.88 


0.89 


0.01 


1 


Cardiology 


-9 


212 


0.86 


0.87 


0.02 


2 


Nephrology 


-6 


43 


0.96 


0.97 


0.00 





Neurology 


-4 


101 


0.88 


0.89 


0.01 


1 


Pulmonary Disease 


-3 


62 


0.88 


0.93 


0.05 * 


5 


Internal Medicine 





917 


0.76 


0.81 


0.05 ** 


6 


RARc 


n/a 


798 


0.77 


0.84 


0.07 •* 


10 


Anesthesiology 


-11 


354 


0.72 


0.82 


0.10 •* 


15 


Pathology 


-10 


103 


0.79 


0.86 


0.06 * 


8 


Radiology 


-10 


338 


0.79 


0.85 


0.06 *• 


8 


Surgery 


n/a 


1994 


0.81 


0.84 


0.03 •• 


4 


Obstetrics/Gynecology 


n/a 


417 


0.80 


0.82 


0.02 


3 


Oral Surgery (Dentist) 


n/a 


65 


0.64 


0.68 


0.04 


6 


Thoracic Surgery 


-14 


69 


0.83 


0.87 


0.03 * 


4 


Ophthalmology 


-11 


214 


0.83 


0.85 


0.02 * 


2 


Neurosurgery 


-10 


69 


0.76 


0.81 


0.06 


7 


General Surgery 


-8 


373 


0.84 


0.88 


0.03 ** 


4 


Orthopedic Surgery 


-8 


324 


0.78 


0.83 


0.05 ** 


6 


Plastic Surgery 


-8 


63 


0.87 


0.91 


0.04 * 


5 


Urology 


-6 


130 


0.71 


0.76 


0.05 •* 


7 


Dermatology 


-1 


116 


0.85 


0.83 


-0.01 


-1 


Otolaryngology 


2 


141 


0.77 


0.84 


0.08 ** 


10 


LLP 


n/a 


1030 


0.76 


0.78 


0.02 * 


3 


Podiatry Surgery 


6 


113 


0.85 


0.89 


0.04 ** 


4 


Chiropractic 


12 


529 


0.47 


0.49 


0.02 


4 


Optometry 


20 


388 


0.86 


0.88 


0.02 * 


2 



Source: HCFA Part B Monitoring System: National Claims History Physician Sample File. 

NOTE: LLP = Limited License Practitioner; Oral Surgeons (Dentists) are also LLP but included with 

Surgeons for this analysis, 
a Data for the six broad specialty groups may include physicians in detailed specialties not shown, 
b Percent change in average price per service forecasted by HCFA in Federal Register 56(227), Nov. 25, 1991. 
c Subtotal for radiology, anesthesiology, and pathology. 

* * = statistically significant at .01 level 

* = statistically significant at .05 level 
n/a = not available 



TECHNICAL NOTE NO. VIII-C 

Assignment Ratios by Type of Service 

Comparison of 1991 and 1992 assignment ratios for the 28 types of service suggests that 
office visits and hospital visits had particularly strong and widespread growth in 
assignments; percentage point gains ranged between 4 and 10 (see accompanying table). 
Other types of service also tended to have higher assignment ratios in 1992, but the 
gains were often smaller or not statistically significant. (As with the performance rate 
and mean allowed charges by type of service, the significance criterion was 0.01.) The 
few decreases in the ratio, seen in some States, tended to be small and were not 
statistically reliable. 



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Appendix IX 
Other Relevant Activities and Future Work 



Prepared by: Joan L. Warren, Ph.D. 

Office of Research and Demonstrations 

Health Care Financing Administration 

April 1994 

Revised May 31, 1994 



Appendix IX 
Other Relevant Activities and Future Work 

The statute requires the Secretary of the Department of Health and Human Services to 
include as part of this annual Medicare physician payment report recommendations: 

(i) Addressing any identified patterns of inappropriate utilization, 

(ii) On utilization review, and 

(iii) On physician education or patient education. 

This appendix discusses the efforts under way in the Department regarding each of 
these issues. 

I. Addressing any identified patterns of inappropriate utilization 

The Agency for Health Care Policy and Research (AHCPR) in the Department of 
Health and Human Services was estabhshed by the Omnibus Budget Reconcihation Act 
(OBRA) of 1989 to enhance the quality, appropriateness, and effectiveness of health 
care services. To carry out this legislative mandate, AHCPR is the primary sponsor of 
the Medical Treatment Effectiveness Program (MEDTEP), a program that has four 
components: (1) research projects relating to understanding patient outcomes; (2) the 
development of clinical practice guidelines; (3) development of data bases to support 
effectiveness research; and (4) dissemination of research findings and practice 
guidehnes. 

MEDTEP's most ambitious research projects are the "Patient Outcomes Research 
Teams" (PORTs). These projects are major 5-year studies. The work of the PORTs 
includes syntheses of the literature, analyses of primary and secondary data, and the 
development of clinical recommendations. Another important feature is the 
dissemination of findings, and the evaluation of the dissemination on changes in clinical 
practice. As of December 1993, 14 PORT projects had been awarded. These projects 
address the following clinical conditions: low back pain; total knee replacement; acute 
myocardial infarction; cataract; prostate disease; ischemic heart disease; biliary tract 
disease; hip fracture and replacement; childbirth; diabetes; pneumonia; stroke; low birth 
weight; and schizophrenia. There are also over 90 other MEDTEP research projects 
focused on improving the effectiveness of medical practice by increasing the evidence- 
base for clinical decisionmaking. 

The second major activity of the MEDTEP is the development of clinical practice 
guidelines. The guidelines are prepared by panels of private sector experts and 
consumers or by contract with non-profit entities. They focus on clinical conditions and 
procedures that affect many people, are expensive, involve wide variations in current 
medical practice and patient outcomes, and are important for Medicare and other 
public programs. As of December 1993, clinical guidelines have been released for 

Appendix IX- 1 



urinary incontinence; acute post-operative pain; prevention and early intervention of 
pressure ulcers; and management of cataract; depression; and sickle cell disease. 
Practice guidelines for additional topics are in various stages of development and peer 
review. 

Health care providers, educators, and consumers may use these guidelines to help 
reduce uncertainty in the prevention, diagnosis, treatment, and management of health 
conditions. Findings from the PORTs and other similar research, as well as 
comprehensive literature reviews and research syntheses, are used to develop and 
update these guidelines. 

In addition to creating clinical guidelines, AHCPR has initiated the process of 
developing the guidelines for medical review criteria, standards of quality, and 
performance measures. AHCPR has awarded a contract to the American Medical 
Review Research Center (AMRRC) that includes translating three guidelines (urinary 
incontinence, acute post-operative pain, and benign prostate hyperplasia) into medical 
review criteria that can be applied by peer review organizations (PROs). Additional 
contracts will include the translation of other guidelines for use by a variety of health 
care and medical review organizations. 

To support this work, as well as future efforts to improve the validity and reliability of 
medical review methods and procedures, AHCPR has also established the "Workgroup 
to Develop Methods for Deriving Review Criteria, Standards of Quality and 
Performance Measures." A Federal Liaison Group for this workgroup includes 
representatives of the Health Care Financing Administration (HCFA), the Department 
of Veterans Affairs, and the Department of Defense as well as AHCPR. Active 
involvement with the workgroup, along with HCFA and Peer Review Organization 
(PRO) involvement in the development of medical review criteria based on clinical 
guidelines, will help refine and focus efforts to identify inappropriate patterns of health 
care utilization. 

HCFA has the primary responsibility for monitoring various changes occurring during 
the new Medicare physician payment system. HCFA will utilize MEDTEP findings to 
help identify patterns of inappropriate use and address them through the PROs. 

II. On utilization review 

The PROs, under contract to HCFA, are required by law to assure the quality of care 
received by Medicare beneficiaries. Historically, case review has been the primary tool 
to achieve this goal. In a major effort to advance the efficiency and effectiveness of 
PRO monitoring efforts, the Medicare Quality Indicators System (MQIS) was 
developed. MQIS will be used to profile patterns of medical care, and allow HCFA, 
medical providers, and consumers to determine when practive patterns differ from 
established practice guidelines or medical consensus. Though this system will initially be 

Appendix IX-2 



developed to examine care for hospitalized patients, it will eventually be merged with 
other billing records to describe a much broader range of medical services. MQIS will 
also examine outcomes of care and allow a systematic analysis of the vahdity of billing 
codes. 

Initially, MQIS will be capable of profiling medical care for only he most common 
conditions. Over the ensuing years, the system will be expanded to cover the full range 
of hospital admissions. MQIS will require a consistent, reproducible methodology for 
examining practice guidelines, identifying areas of consensus in medical care, and 
coverting these findings into suitable profiles for medical practice. Rapid changes in 
medical knowledge and improvements in medical practice will require a methodology 
for continuously improving these profiles. Most importantly, development and 
maintenance of MQIS will require continuous interaction between HCFA, the PubHc 
Health Service, PROs, and the medical community to assure that these profiles do 
indeed reflect the state of the art of medical practice and are useful in supporting and 
monitoring efforts to improve medical care. 

m. On physician education or patient education 

Since its inception in 1984, PRO review has been centered on the case-by-case review 
of individual medical records, selected primarily on a sample basis, using essentially 
intuitive local clinical criteria. There are serious shortcomings to this approach. It is 
costly, compartmentalized, and confrontational. Most importantly, it holds httle hope 
for fostering meaningful change in provider and practitioner behavior. These 
shortcomings are discussed in the 1990 Institute of Medicine (lOM) report, "Medicare: 
A New Strategy for Quahty Assurance." 

HCFA has developed a new strategy consistent with the lOM recommendations to 
continuously improve quality of care, and to strengthen the ability of health care 
organizations and practitioners to assess and improve their own performance. This 
strategy is the Health Care Quality Improvement Program (HCQIP), which will move 
the PRO program from its emphasis on individual (and often isolated) clinical errors to 
helping providers improve the mainstream of medical care. 

The HCQIP has its conceptual foundations in the health care variations research of the 
last decade-which examines variabihty in care and outcomes among providers and 
geographical areas-and in the continuous quality improvement models now being 
adapted to health care from the experience of other industries. Under the HCQEP, 
PROs are beginning to utilize statistical methods to examine variations in both the 
processes and outcomes of care. PROs will then share these data with hospitals and 
physicians, and work with them to interpret and apply the findings. 

In addition to physician education, HCFA is developing a project to improve the ability 
of consumers to make more informed health care choices, either in the health plans 

Appendix IX-3 



they select or in the services they use. This is a part of a long-term commitment by 
HCFA to change and improve communication of information to HCFA beneficiaries. 
Expanded consumer information strategies are also a basis for plan selection under the 
Health Security Act and other health reform proposals. 

Future Work 

1. In addition to the beneficiary-based monitoring system, HCFA is currently 
developing an analysis file for monitoring the diffusion of emerging technologies. 
This specialized file is intended to provide information for monitoring access to 
these technologies, and for the Secretary's consideration of changes in technology 
in formulating Medicare Volume Performance Standards rate recommendations. 
The first phase of this effort resulted in the production of an inventory 
containing descriptions of emerging technologies and codes to be used in the 
monitoring system. An initial listing of 92 technologies was developed. Each 
technology was described in terms of: its use in clinical medicine, phase of 
diffusion (early, mid, late), associated HCPCS code(s), relationships to other 
relevant technologies; and, effects on cost. 

Phase two of this effort is currently underway and involves the development of a 
set of analytic files derived from HCFA's National Claims History (NCH) using 
the inventory specifications. The monitoring system should provide an empirical 
perspective of the extent to which emerging technologies contribute to service 
volume and expenditures under Medicare. Future access reports to Congress 
will include empirical results tracing (where possible) historical trends in service 
volume diffusion patterns and expenditures from 1989 through 1993. Plans call 
for updating the technology inventory periodically with future revisions of 
HCPCS and technology assessments. 

2. There are plans in HCFA to monitor access by small areas and to address the 
question whether differences in utilization for certain procedures signify racial 
barriers or barriers related to socioeconomic status. These plans include linking 
1990 ZIP code level data from the Census Bureau with Medicare administrative 
data to undertake new analyses. 



Appendix IX-4 

i! U.S. GOVERNMENT PRINTING OFFICE: 1994 — 381-97if/20262 



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